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Trial & Error by Michael Mouw, MD

Mistakes, near-misses, and bouncebacks. Chances are we mere mortals who have been at this a while have a case or three we aren't proud of. The trouble is that the medical culture doesn't exactly encourage admitting one's human errors, at least not outside M&M peer review.

This blog, moderated by Michael Mouw, MD, aims to provide a collegial forum for emergency physicians to share lessons they learned from mistakes made in the practice of emergency medicine.

Submit your case about errors you've learned from, and we will publish it here with a brief analysis by Dr. Mouw. All cases will be published anonymously, though you may choose to include your name, as Dr. Mouw has done with the first case.

Submit your case to emn@lww.com.

A few rules:

  • Mind HIPAA! No names (patients or otherwise) or identifying characteristics.
  • Cases should not exceed 500 words, and will be edited for style, grammar, length, and clarity.
  • Photographs, clinical images, and lab reports are welcome, and should be submitted as separate attachments. Images should be 300 dpi and in jpg, tif, gif, or eps format.
  • Authors are responsible for obtaining consent from patients, family members, and health care professionals depicted in images, and must attest to EMN that consent was obtained.
  • Authors should provide their full name and contact information for verification purposes. This is strictly to ascertain identity and will not be published without permission.
  • Include all relevant information about the patient in the case as well as a full description of the patient's symptoms, diagnosis, treatment, and outcome.
  • Only post cases outside the statute of limitations. Please provide your retrospective insights and analysis, and any pertinent references you've found helpful.
  • Comments about the cases posted are also welcome. Be kind. Submit yours to emn@lww.com. Word limit: 200 words.
  • Submission grants permission to publish in EMN, its website, enews, and other formats.

Monday, July 8, 2019

BY MICHAEL MOUW, MD

It was 3 a.m. one night in 1993. I was working at an urban teaching hospital with no MRI or real-time radiology reads on plain films and before spiral CTs. The arrival of the man in bed 16 would have been tough to miss. He was one of those patients you aren't exactly eager to meet, but you're alone.

Hey, doc! I need something for back pain!

EMS was disgusted. He says he can't walk. We found him sitting on the toilet alone. The place had dirty needles everywhere. He left Elsewhere General yesterday. Treated a left arm abscess.

Swamped, I managed a cursory look. Disheveled, malodorous. Obvious healing skin graft to left AC fossa. Let's sit up so I can see your back.

I pull him up. He grimaced. Damn, doc, that hurts! I percuss his spine. Hurts everywhere. Not helpful.

Let's see you move your toes.

Nothing. I can't.

He might have an epidural abscess, and three patients are ahead of him for CT. No way I'll dispo before shift change. OK. I'll give you some IV Toradol, and get some tests.

I'm allergic to Toradol.

I roll my eyes. OK. I'll give you some morphine then.

I order labs, a lumbar spine CT, plain films of the entire spine, and call CT to reshuffle the queue. Thankfully, staff obtains IV access. Something is going right.

I mount his films on the view box. Nothing obvious, but no surprise because his pain is lumbar. I'm finally caught up, so I return for a better exam. His legs are crossed. So much for not being able to wiggle his toes. He wants more meds. I thought you said you couldn't move your legs?

I can't!

Then how did you get them crossed? Patellar reflexes are brisk. Ankle jerks also brisk, plus clonus. Hmm. That means something. I'm interrupted by the radiologist with a negative CT report. I call Elsewhere General: Oh, yeah. That guy was always begging for pain meds.

Now I've got him!

I return to his bedside, lean on the rail. Shift change is nigh. If you can't walk or move your legs, how did you get to the toilet? And how did you manage to cross your legs?

He reached out, placing his hand over mine on the bed rail, imploring. Doc, I ain't lying. I can't walk.

And I believed him.

OK. Fair enough. I'll admit you to sort this out.

I called the admitting resident. She pushed back. You want me to admit an obvious drug seeker who's malingering? Neurosurgery probably won't come to see him!

I persisted. She reluctantly agreed. I went home to bed. When I returned that night, a day-shift colleague accosted me. Hey, remember that shooter you saw? My heart sank. Yeah, why?

Medicine sent him home after you left, and radiology called him back. X-rays are in there. They sent EMS, and on return he had flaccid paraplegia. Went straight to the OR.

I check the films. Only now, illustrating my incompetence, there's an arrow pointing to the space that had previously contained his now-collapsed T10. Luckily, he had complete return of function after drainage of his huge epidural abscess.

 

Comments:

  • My judgment was clouded by my visceral reaction to a malingering drug-seeker. I didn't study his films closely enough.
  • Cognitive overload: Did I mention it was single coverage, and I was swamped?
  • Knowledge deficiency: Clonus is a long tract sign that was signaling the onset of cord compression. I should have been armed with that finding and called neurosurgery myself.
  • Shift change: Need I say more?
  • Anchoring: Plus one for considering spinal abscess, but minus two for anchoring on lumbar. Spinal pain doesn't localize accurately. I've had two cases of spinal abscess since then where this lesson served me well. I had to push past MRI tech objections to image the entire spine rather than just a segment.

Malingering and real pathology are not mutually exclusive.

Sunday, July 7, 2019

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