Sunday, March 7, 2010

The Unasked Question

A large heavy package arrives at my office. I am expecting these charts after my conversation with the attorney. He says, "Doctor deMaine I'm representing a prestigious teaching hospital related to the death of a firefighter." He briefly explains the issues involved and I agree to review the case.

The large cardboard box contains hundreds of xeroxed pages from treating doctors outside the hospital as well as the complete hospital records and the autopsy report. I lug all this home and spend hours that evening sifting and sorting the time-line of events. This 34 year old female fire fighter begins to notice being easily winded with exercise over the past few months. She sees her internist who checks her heart and lungs including a chest x-ray and EKG. Her heart rate is 90 which is within a normal range but higher than her usual rate of 70. This isn't enough to raise red flags at this point, but there's no diagnosis for her symptoms.

Subsequently, at a house fire, she needs to scale a ladder carrying a hose. Becoming very winded, she collapses and has a brief "seizure-like" episode. Medic 1 responds and she is taken to the hospital where she is evaluated in the Emergency Room. Her blood pressure is fine, the heart rate is 110, and the neurological exam is normal. The neurology service admits her for observation and a "seizure workup".

After two days in the hospital, no diagnosis is established. The shortness of breath history is noted. The pulse rate never drops below 110. She is discharged from the hospital with an appointment made for the Pulmonary Clinic in two weeks. Three days later, she collapses in the shower. Her roommate calls 911 and she's brought to the hospital where the diagnosis of a pulmonary embolus is established. She has sudden cardiac arrest in the x-ray department and dies undergoing CPR.

I notice from her outpatient record buried in her history that she has been taking birth control pills for the past six months. Also there is no history of asthma, allergies, or any lung disease.

The attorney is not happy when I tell him that I can't testify for the defense. "Settle this one and try to stay away from a jury", is the best advice I can give him. "Look," I said, "if you framed the case with the appropriate information, any emergency physician would come to the diagnosis. You have a young woman on birth control pills who is becoming short of breath. This is a red flag for blood clots beginning to clog up the lungs. They start in the upper legs and pelvis and have no local symptoms - but can be deadly as they break loose and are pumped through the right side of the heart into the arteries of the lung. The heart rate goes up and I'll bet you anything that her neck veins were distended (from the obstructed blood flow). The 'seizure' was a red herring. The patient shouldn't have been discharged without a diagnosis. Basically no one put two and two together. The right questions weren't asked, so the right diagnosis was never considered. A simple lung scan would have made the diagnosis and anti-coagulation would have saved her life."

The attorney angrily told me that I wasn't being helpful to the medical profession and that I was prohibited in testifying for the plaintiff (which I very much dislike to do anyway).

Comment: This was a very sad death and very preventable if only the diagnosis of pulmonary embolism had been considered. There aren't many things that cause a young woman on birth control pills to have severe shortness of breath, but this patient was felt to have a brief "seizure" and admitted to the neurology service. Each specialty tends to focus in its area and we naturally try to fit the patient into a learned pattern. The smartest doctors I know (please count me out) have a sixth sense in a case like this; an ability to step back and ask the right questions.

All this said, I don't think the doctors sued were bad. Dragging them through the courts when they all felt guilty and terrible doesn't help anyone. I hope that in tort reform that we can develop expert review panels who can review a case like this, bring about a fair settlement, and not clog up the legal system for years with expensive "expert witnesses", discovery, rulings, appeals, etc.

1 comment:

  1. Thank you so much for another informative, fascinating post.