Pages from the Philips Seeking God's leading in medical missions

Mistakes & Failures

First, a big praise.  We got to 100% of the support we needed for our upcoming trip to India as of one week ago!  Thank you to all of you who have been praying for our trip as well as the many who have so generously given to help make this trip a reality.  This whole support raising process has always been an incredible process of faith building for us.  It is amazing to see how God moves in the hearts of people to generously give to make this possible.  Of course, I would like the whole process to work on my time frame but often God uses delays and frustrating days to continue to increase our faith and to trust HIS provision.  Yet again we were amazed at the variety of people who gave and especially moved by those who gave who did not have much to begin with – a true lesson for us about sacrificial giving.  We are also excited because we are now less a week away from leaving for India.  We leave next Saturday, April 2nd.  A couple of things you can be praying for:

• Travel mercies as we spend over 24 hours in flight and travel through Paris and Bahrain on our way to Delhi and then as we spend another 24 hours on a train on our way to Raxaul.
• Pray for supplies to be become available for us to take to the hospitals in India.  We have hit several roadblocks with getting supplies donated from Parkland due to hesitation from the legal department and we need God to work to allow us to have several pieces of equipment to take to India.
• That our hearts would be in the right place and that we would rely on God and not ourselves as we make this trip

In my continuing series of posts on themes from the emergency department, I wanted to use this post to write about several patients where I made a mistake or did not pick up on a condition fast enough to prevent them harm.  I think very few physicians want to speak about mistakes because they ruin our sense of infallibility but I feel like the lessons I’ve learned for patients where I made a mistake have been invaluable in my development as a young physician and have taught me to hold on to my humility.  I’m human and will always make mistakes but sometimes these are hard lessons when they involve the life of a patient.

The first patient who comes to mind was a 49 year old lady I met in my first year of residency.  She was a pleasant African American woman who did not want to see a doctor.  In fact this visit to the ER late one evening was the first visit she had with a physician in almost 30 years.  She had last seen a doctor when she delivered her son.  She was an overweight woman, probably close to 300 pounds.  Even though she struggled with obesity, she had an air of confidence and she carried her head proudly and she would greet any that came to visit her with an infectious smile.  I remember the details clearly because this encounter with this woman and what happened next has been seared into my memory.  She had come in because of a mass that had developed in her left breast over the past few months.  She finally came into the ER because the mass had gotten so large that it was causing her quite a bit of chest pain.  As she told me the story, I knew almost immediately that I would be diagnosing her with breast cancer and that it was probably too late to do much about her cancer because it had grown so large.  She denied any other complaints except for this mass and the pain it was causing in the left back side of her chest.  After I asked the nurse to come into the room to chaperone my exam, I asked her to undress so that I could examine the affected area.  The difference between her breasts were readily obvious – her left breast was significantly larger than the right and I could feel a large hard mass almost 10 cm across.  The rest of the exam was normal.  I was worried that the pain at the back of her chest was due possibly to the tumor invading one of the ribs so I got a chest x-ray to see if I could see any evidence of that.  The initial chest x-ray interpretation by the resident overnight came back as normal.  By this point her son had also joined her and I gave them the diagnosis – she probably had breast cancer and she needed an urgent mammogram and biopsy to make the diagnosis so that treatment could be initiated.  I got her name and number so that I could call the breast clinic the next day to get her an overbooked appointment for the next week so she would not get lost in the system.  The clinic worked hard to work her into the schedule and she was seen in about 4 more days.  A sad diagnosis but I was glad that I was able to pull some strings to get her into clinic quickly so that she could get the treatment she needed…

I worked another week in the department and I was about half way through another shift when I saw this lady’s name pop up on the ER “To be Seen” list.  Immediately I was concerned.  I spoke to the charge nurse to have this patient come to my section of the ER since I had seen her last week.  Her son brought her into my section of the ER but she was now in a wheelchair – I had a sinking feeling in my heart.  Something had to be wrong.  I started my conversation with her – she was smiling because she got the same physician again.  She had indeed followed up with the breast clinic a couple of days after she had seen me and they performed a mammogram which showed a large breast cancer.  She was schedule for a biopsy the next week.  However she went home and about two days later noticed she was now having some numbness in her legs and soon her legs could no longer hold her weight.  She thought she was getting more tired and waited until her son was off work before she finally asked him to bring her to the ER because she could no longer walk.  Oh, how my spirit fell!  She must have a spinal cord lesion.  On my repeat exam that day she could do everything well with her arms but as I went down I noticed that she could not feel me touch her very well below around the top of the abdomen.  When I asked her to lift her legs up she tired but her legs would not obey.  I immediately called the spine surgeons while I called the MRI techs in from home to get a stat MRI done of her spine.  Within about two hours the images confirmed what I knew based on the physical exam – she had a large tumor in her vertebrae that had caused collapse and now was compressing her spinal cord – essentially rendering her a paraplegic.  She was taken to the OR the next day – her surgery was complicated and she suffered a partial stroke.  I felt so horrible – I had just seen her last week and she was fine – what did I miss?  Her neurological exam seemed normal but was it?  Had I looked carefully enough?  Was her chest pain actually referred pain from her back as the tumor started to press on the spinal cord?  I went back and looked at the x-ray I had taken the day she first came – it was hard to see much because of her weight but then my heart sank again when I saw the attending over-read from the next day – “likely compression fracture of several thoracic vertebrae of unknown time course.  Suggest clinical correlation.”

After the surgery I visited her a couple of times in the hospital – she never once complained about her lot.  She was not mad at anyone – “Doctor, it was my time.  God knows all things and it was my time.”  She was finally released to a nursing home several weeks later – by this time her full evaluation showed breast cancer in multiple locations and she was a candidate only for palliative chemotherapy.  I kept her on my list of patients to follow so that I would know when she came back to the hospital.  I’ve seen her a couple of times since then – once when she got a decubitus ulcer and became septic from it because she could not feel anything below her abdomen.  I saw her around Thanksgiving – her son was working that day but I asked her what her favorite food was so that I could get her something special.  I found some fried shrimp for her and went with Karuna and Luke to deliver that to her along with some pictures they colored for her.  She was extremely grateful and thoroughly enjoyed her shrimp.  She died this past December – almost two years from when I first met her.  I still think about her and what I missed.

The second patient was a Hispanic woman in her late 50s with severe rheumatoid arthritis.  I met her when I was working a shift in the ER late in my first year.  She was the prototype of a difficult patient.  She was in one of our hallway beds screaming because she needed pain medicine.  When I went to talk with her I couldn’t get much out of her except that everything hurt – her neck, her back, her arms, her legs.  If histrionic personality disorder could have a poster to represent itself it would have been her.  Her wailing only became louder when her family approached her.  Even her family was getting tired of her excessive demands – always wanting pain medicines, always complaining that everything was tingling.  She lay in a fetal position while I tried to examine her – she was not very cooperative.  I could get her to squeeze my hands and push her legs up and down against my hand but that was about it.  She wanted pain medicine and she wanted it now!  I gave her a fairly high dose of morphine and some anxiety meds and soon had her calmed down enough to talk with her family and look over her records.  I looked at the multiple scans that had been done on her – nothing seemed to point to an obvious diagnosis.  The only abnormality I could find was a mention in a CT neck scan of 5 mm of subluxation between C1/C2.  It was still early on my career and I didn’t quite know what to make of it – I figured she had been sent home previously with that scan result – surely that must not have been that important.  I finally convinced the family to take her home and prescribed her some pain medicines – relieved that I did not have to deal with what believed to be classic narcotic dependent behavior.  As I routinely do with most patients I see, I pulled up her chart a couple months later to see if someone ever figured out why she kept asking for pain medicine.  She indeed came back to the ER about a month later with the same complaints.  Thankfully she was seen by a senior level ER resident who decided to ignore the multiple previous charts where it was documented that there was nothing wrong with her except she was looking for a fix.  He stumbled upon that CT scan that I had also looked at and decided to order an MRI.  It showed severe C1/C2 atlanto-occipital subluxation by this point almost 7 mm and that this subluxation was causing severe cord compression and myelopathy.  Of course there was the answer that explained everything.  Indeed it felt like everything hurt and that everything tingled because every nerve in her body had receptors that traveled through this region and thus she was always in pain.  She was still in the hospital when I pulled up her chart and so I visited her in the hospital.  She was completely transformed now that her spine was fixed – she was no longer in partially narcotic induced coma, she could actually smile.  It was an important lesson to me in always believing the patient – I’d much rather be duped into over evaluation and over treating pain rather than miss someone who legitimately has something wrong.  Since that experience, this thought of never dismissing someone with real disease has saved the life of two other patients.  These were individuals where everyone else taking care of that person said he or she was  just making it up – a man in his 40s with with an inferior wall heart attack (who had just been seen at another facility and sent home after a negative cardiac stress test and echocardiogram) who came in screaming and rolling on the floor because he said he was in pain (probably the most over the top description of pain I have yet seen in residency) and another lady who had a duodenal perforation from taking too many anti-inflammatory pain medicines whom the nurses had said was just drug seeking because she kept complaining of pain.

I think that is it for this post.  Hopefully I’ll have time to write one more post about going the extra mile before we leave for India.  Have a blessed week!