Wednesday, March 15, 2006

Medical Mistakes

Fat Doctor writes about a medical mistake:

His first push of the PCA pump button delivered a lethal dose of narcotic. Thankfully, he was resuscitated and after a long sleep in the ICU he is recovering well. [His wife] wrote, "We don't want to sue or anything, but we wish we knew what happened…"

… This family's surgeon immediately told Friend about the PCA problem and she easily accepted it as an accident. Now, to complete the process, they need to tell her how the incident report was handled and what was discovered during the investigation. Then she can rest easy, knowing the problem has been addressed and will be less likely to affect another patient next week.

That’s the way a mistake should be handled. I can tell you how it shouldn’t be handled:

Sixteen years ago, my father, a non-smoker, was diagnosed with a large mediastinal mass. I accompanied him to the thoracic surgeon (at the hospital where I was an attending) and my father expressed surprise that he could have such a large mass when a chest X-ray 8 months earlier had been normal. The thoracic surgeon explained that these lesions could grow very quickly.

Curious, I went the next morning and pulled the film. It had been a pre-op chest X-ray prior to cystoscopy for bladder stones. I was horrified to discover that the mass was in the original film. It was tiny then, but it had been picked up by the radiologist and read as lymphangitic spread of unknown primary. I called my father’s internist and was even more shocked to discover that he knew; the thoracic surgeon had known also before he calmly lied to my father. The doctors had decided among themselves that it would be “better for his morale” if they kept the truth from him. It had been an “administrative” error. The radiologist had never called the urology attending and the urology attending had never looked at the chart.

I gave them no choice. I told the internist that if he did not tell my father, I would tell him. He reluctantly shared the truth with my father, but the damage was done. Not just the medical damage; my father died 8 weeks to the day from the diagnosis, after failing to respond to a variety of treatments. The emotional damage was almost as bad because he could no longer trust the doctor who had cared for him for many years, just when he needed to be able to trust his doctor most.

No one ever apologized to him or to me. Needless to say, my mother sued, but that is a story for another post.


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