AW was a 75-year-old woman admitted to the medical intensive care unit with respiratory failure related to pneumonia, systolic heart failure and COPD. After two weeks of treatment, and uneven improvement, she developed acute kidney injury, probably related to medication toxicity. A few weeks later, her family opted to have her taken off the ventilator. She died soon after.
28 years ago, during the second year of my residency, I made a mistake while caring for AW. Trying to come to terms with my error, I started a journal. I promised myself I would keep track of mistakes and “near misses.” In this journal, I enter any high stakes medical events from which I might learn. Although I keep the book locked away in my desk, it is never far from my mind. Some of the entries are a sentence long; others come with their own reflection.
I’ve always considered that one of the true gifts of a career in medicine is its power to keep you humble. Anytime I think, “Boy, I’ve really gotten good at this,” something happens to remind me how hard the job is: an unknowable number of illnesses presenting in an infinite number of ways. My journal is this gift of humility in its physical form. I occasionally thumb through the journal in much the same way I occasionally thumb through my college and medical school rejection letters.[i] A few years ago, I reflected on these stories and came up with a list of “Commandments for Avoiding Clinical Errors.”[ii]
Pay attention to the chief concern recorded by the nurse
Really attend to the vital signs, they are vital
Always assume the doctor who saw the patient before you was smart but never blindly accept somebody else’s diagnosis
Consider drug-drug interactions and renal function before writing any prescription
If your decision to discharge a patient will keep you up, reconsider that decision
If your decision to not evaluate a concern will keep you up, reconsider that decision
Never exclude a diagnosis because of the absence of a sign or symptom
Never be afraid to ask for help
Slow down, relax, listen, think
Keep a list of errors you have made and review it often
Here are the stories behind the commandments.
1. Pay attention to the chief concern recorded by the nurse
MO was a 70-year-old woman who presented to the emergency room with urinary complaints. It was a busy evening, and I was moving quickly from patient to patient. When I entered the room, MO was sitting in a gown, on a chair next to the bed. She did not look unwell. I asked her what brought her in and she gave me a list of seemingly unrelated, non-specific concerns. There was tingling in her legs, burning with urination, urinary frequency, and at least one episode of urinary incontinence. She had no significant past medical history. She struggled a bit getting up onto the bed for a physical exam, but she was 70 and mentioned that she thought she had arthritis. Her urine sample revealed a urinary tract infection. We were both satisfied that this could, conceivably, explain her symptoms. I wrote her for antibiotics and sent her on her way.
Forty-eight hours later, back for another shift, I picked up a chart and realized she was back. This time I saw the note from the triage nurse. It read, “seen two days ago, diagnosed with UTI, now unable to walk.” My heart jumped into my throat only to crash to the floor when I read the triage nurse’s note from 48 hours earlier, one I had not read the first time I saw her:
“70-year-old woman sent to ER by primary care physician. Just diagnosed with metastatic cancer. Chest x-ray with innumerable pulmonary nodules. Now with urinary symptoms. PCP worried about cord compression.”[iii]
I had missed why MO was in emergency room the first night. She was glad to be sent home with a harmless, easily treatable cause of her symptoms. She assumed I knew the history (a perfectly reasonable assumption) and was probably afraid to even voice the more sinister possibilities. I was an unknowing partner in a folie a deux. The two-day delay in her care had had devastating consequences.
I visited her in the hospital two days later to apologize. The inpatient team had determined the extent of her cancer and she and family had decided to begin inpatient hospice. I told myself that my error probably had not made a difference. However, I’ll never be sure whether treatment for early cord compression would have saved her ability to walk and led her and her family to make different decisions about her care.
2. Really attend to the vital signs, they are vital
While I was working in our urgent care, a 35-year-old woman came in with abdominal pain. She had awoken with pain in the left lower quadrant of her abdomen. Over the next four hours, the pain improved. By the time I saw her, she reported just some “achiness,” so she apologized for wasting my time. Her exam was also unremarkable, a little tenderness in the LLQ but nothing that would have suggested an emergency.
Vital Signs: Temperature: 37, Pulse: 127, Blood Pressure: 82/50, Respiratory Rate: 12
Despite the reassuring medical history and physical examination, her tachycardia and hypotension demanded further investigation.
Her pregnancy test was positive and an ultrasound of her pelvis revealed a ruptured ectopic pregnancy.
She was in the operating room two hours later.
3. Always assume that the doctor who saw the patient before you was smart, but never blindly accept somebody else’s diagnosis
TP was transferred from a community hospital with a dissection of the thoracic aorta.[iv] He was an 82-year-old man with mild cognitive impairment who had presented with chest pain. A CT scan, read by the radiologists at the outside hospital, revealed the dissection. The physician caring for the patient determined that this was a chronic dissection not needing urgent management, and unrelated to the patient’s chest pain, which was getting better.
The physician felt, however, that the patient would be better served at a tertiary care hospital.
TP was accepted for transfer to the surgical intensive care unit at the hospital at which I worked. The attending physician in the ICU reviewed the outside CT scans and felt that there was, in fact, no dissection. He transferred the patient to the general medical service for control of his blood pressure and management of his delirium.
Two hours after transfer the patient suffered a cardiac arrest.
Post mortem diagnosis: Acute rupture of the thoracic aorta.
4. Consider drug-drug interactions and renal function before writing any prescription
I cared for AW, the patient referenced at the opening of this reflection, in the medical intensive care unit for weeks. She was admitted initially with a community-acquired pneumonia that led to respiratory failure, her underlying diagnoses of systolic heart failure, COPD, and severe chronic kidney disease made her condition tenuous. In our dark ICU humor, we joked that in her state, one extra cup of coffee would throw her into heart failure while missing a cup would put her into kidney failure.
After two weeks of careful management in the ICU she developed a healthcare associated pneumonia. The otherwise diligent intern mis-dosed her antibiotic (gentamicin), failing to consider her already poor kidney function. She was placed back on the ventilator, now with an acute kidney injury, almost certainly related to medication toxicity, added to her list of problems. Three weeks later, her family had her extubated and she died about four hours later.
5. If your decision to discharge a patient will keep you up, reconsider that decision
6. If your decision to not evaluate a concern will keep you up, reconsider that decision
These two commandments can be illustrated with one case. TC presented to our urgent care saying, “I have appendicitis.” After evaluating him, I was doubtful. He had very mild right lower quadrant abdominal pain without anorexia, nausea, vomiting or diarrhea. I could only find abdominal tenderness by palpating deeply (very deeply) in the right lower quadrant. His vital signs were normal and his complete blood count revealed nothing.
What made me nervous? Before coming to Chicago, TC worked as a general surgeon in his native country.
This case was going to keep me up.
CT scan results? Appendicitis.
Thank you for the consultation TC.
7. Never exclude a diagnosis because of the absence of a sign or symptom.
One of my favorite points to make when I teach diagnostic reasoning is that positive findings are far more important than negative ones. There are very few situations in which the absence of a finding rules out a diagnosis while there are situations when a positive finding rules in a diagnosis. Pleuritic chest pain is a classic finding of a pulmonary embolism but most patients with an embolism do not have pleuritic chest pain. In contrast, if a doctor hears a third heart sound in a patient who is short of breath, that patient has heart failure. We have posted some of our data supporting this point on sensible medicine. (FUTURE HYPERLINK)
8. Never be afraid to ask for help
Ok, I’ll admit, this is something my parents taught me. None of us know everything. So much of good medicine is not about smarts or memory, but about experience. I seldom go a week without running a case by a colleague or having someone come into the exam room with me to examine a patient. Sometimes, just presenting the case, hearing myself walk through the details, gives me new insights. Other times, a colleague will suggest a diagnosis I would have never considered.
One particularly memorable instance: I saw a man in his 50s in the urgent care. He had developed swelling and pain on the back of both hands. He could tell me when his symptoms began, almost to the minute. On exam there was inflammation of both the joints and tendons of his hands. I was flummoxed. I considered gout, rheumatoid arthritis, psoriatic arthritis, disseminated gonococcus and a few other diseases. None of my hypotheses really made sense. I grabbed a colleague with the usual, “Can you take a look at someone with me?” My colleague smiled as he looked at the man’s hands and asked a few questions. I could tell he was all over it.
When we left the exam room I said, “I can tell by your damn shit eating grin that you know exactly what this is.”
“Well, are you going to enlighten me?”
“RS3PE. Remitting Seronegative Symmetrical Synovitis with Pitting Edema. I saw it a few years ago and will never forget it.”
9. Slow down, relax, listen, think
A pretty obvious one. We are all too busy and distracted. Our days can be stressful, filling our cognitive slots with noise. Pausing outside the door, clearing your head so you can listen and focus, is invaluable.
10. Keep a list of errors you have made and review it often.
Maybe even turn the list into a Friday Reflection for Sensible Medicine.
[i] Yes, I might have a problem.
[ii] This list has ended up as my “pinned tweet” for years now.
[iii] Cord compression is short for spinal cord compression. Although this can take many forms, a dreaded version is cauda equina syndrome, where malignancy that has spread to the vertebrae, grows and compresses the nerves at the end of the spinal cord. This is considered an oncological emergency as, left untreated, it can have devastating consequences.
[iv] In an aortic dissection, blood “dissects” through the lining of aorta flowing into the wall of the aorta. Even with early recognition and treatment, the condition carries high mortality.
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My cardiac tamponade was diagnosed as gall stones because of a fixed dot on the scan. TThey were about to take me to surgery when the surgeon said we have to figure out what’s going on with her liver first. There was a “shadow” on my liver on the scan. No one caught my muffled heart sounds or distended jugular vein until 5 abdominal scans later the picture happened to catch a glimpse of my engorged pericardium. The shadow on my liver was a distended portal vein. A needle in my chest cured me 5 days later than when I first saw the NP in my PCPs office with excruciating pain in the lower middle of my chest. My PCP was on vacation. Once I was put on the GI track, no one reassessed my heart. Not even a listen.
“Boy, I’ve really gotten good at this.”
In 20 years of being an airline pilot, I’ve said this a few times as well only to come to a similar conclusion. Humbling indeed.