When Doctors Are Wrong

As medical students and resident physicians gain experience they also gain
knowledge and confidence. Consequently, young trainees eventually reach a
level of comfort in speaking with families and patients about prognosis and
disease course. This is part of the purpose of training, as these
conversations happen so often that they are an integral part of practicing
medicine. But it isn’t certain that with experience and confidence also comes
accuracy.

***

Soon after finishing sign-out on a night shift I received a page. The
nurses told me that a patient’s daughter had arrived and wanted to speak
with me about her father. The patient was an elderly but relatively healthy
gentleman who had been admitted with abdominal pain. Multiple imaging
studies had shown little to account for his discomfort. But the pain was so
intense that he could not eat anything. Even going to the bathroom was
difficult — he held in his stool to avoid the agonizing act of defecating.
As a result, he became constipated, which then exacerbated the pain. Thus,
the medical team administered anti-inflammatory treatments, stool softeners, and IV
fluids as they searched for the etiology of this troublesome symptom.

The patient’s daughter asked me about the latest imaging studies and labs
as she sat holding her father’s hand. Buried to his chin under the covers,
the patient participated in the discussion, asking when he would be able to
eat and go to the bathroom easily again. I explained that all the tests had
been negative so far and we were unsure of what was going on. I then left the
room, and the daughter caught up to me in the hallway. She seemed worried,
speaking hurriedly and pleadingly: “How long do you think my father has
left to live? How much time do I have left with him? Should I start making
funeral arrangements?”

The questions took me aback. I had seen plenty of patients in the
intensive care unit
who were on the verge of death and they looked so different from her father
— a profound pallor, somnolence, lethargy, disinterest in conversation
and food. But this patient wanted to eat again, he wanted to see his
family, he wanted to watch basketball on TV, and he was interactive and
conversational. His cheeks certainly did not exhibit the deathly pale hue
of those crossing over to the other side. I assured the daughter of this:
“I don’t think you have to worry about that. The most important thing right
now is that we figure out what is going on. I can’t tell you how long he’s
going to live but I would be shocked if he had only days or weeks left.”

This interaction repeated itself for the next three nights, always with the
same diagnostic uncertainty. On further imaging there was evidence of some
abnormal fluid in the abdominal cavity. Interventional radiologists
extracted the fluid to test it for any cancerous or infectious cells, but it
would take perhaps a week or more for definitive results to come back. In
the meantime, the patient’s pain improved and he moved his bowels without
issue. Even though we didn’t yet have a diagnosis he seemed to be doing
incrementally better each day.

On the fourth night I again saw the daughter and she asked: “You don’t
think I should be planning the funeral for my father, do you? He’s not
going to pass in the next few days?” I understood why she was asking the
question — any child ought to be concerned for the well-being of a parent.
But I was also surprised because her father was on the mend. I told her
that if he continued to improve he would leave the hospital, and his primary
care doctor would follow up the lab results and see him in clinic.

At around 2 a.m. that same night, a voice over the hospital loudspeaker
echoed throughout the halls as I jumped out of my chair: “Code blue, 7th floor, code blue, 7th floor.” There was a
patient in cardiac arrest. I ran out of the workroom and met up with
another resident. Which patient was dying? On my way to the code I ran
through the patients on the coverage list that evening; I did not expect
anyone to pass away. As the other resident and I ran down the hall I saw
the code cart containing all the medical resuscitation equipment necessary
to treat cardiac arrest outside of the room I had visited every night for
the past four nights. My heart leapt out of my chest; I pleaded with some
higher power that it not be that patient. But it was.

The resident, nurses, and I immediately began CPR. The anesthesiologists
burst into the room and stuck a tube down the patient’s throat and into his
trachea to protect his airway as the respiratory therapist attached the
tube to a ventilator to help the patient breathe on his own. After multiple
rounds of CPR, his pulse returned. We wheeled the patient — attached to
tubes, and poles filled with intravenous fluids — to the ICU for closer
monitoring. He didn’t respond to our questions or poking and prodding, but
he was alive.

Alas, as soon as we got to the ICU, his heart once again
stopped beating and his IV line ceased working — his veins (which can
happen as we age) were friable and brittle, and the small vein carrying the
volume and force of the IV infusions burst. Without an IV we could not give
medications. We turned, then, to an

intraosseous (IO) line
. This entails drilling a hole into the bone and infusing medications
through that hole. It is a proven method of administering medications when
physicians and nurses cannot obtain IV access. I opened the IO kit and
attached the drill to the IO needle, placing it on the shinbone and drilling. It
slid into the bone, I detached the drill, and hooked up the
IV tubing to the IO line jutting out of the patient’s bone. At this point,
the code had been going on for nearly 15 minutes and the patient’s family
had arrived. They watched as we furiously attempted to revive their loved
one. At some point a family member shouted “Stop, please, enough!” Time of
death: 2:45 a.m.

I sheepishly held my head down, avoiding eye contact with the family as
they sobbed. The medical team and nurses quietly left the room, leaving the
patient in peace. As I passed by the daughter, I could only say “I’m so
sorry” — little else would have sufficed. Not only did we not save him, but
night in and night out I had given the daughter a false impression that he
wouldn’t die. Perhaps, I wondered, I had been disingenuous in some way.
Either way, I was wrong.

 ***

Alas, physicians are wrong relatively often, and there is ample
evidence for this. In a systematic review in the

British Medical Journal in 2012
, researchers found that each year up to 40,500 adult patients in American ICUs die with a misdiagnosis. The Journal of the American Medical Association published an analysis in 2009, concluding, among other things, that “while the exact prevalence of
diagnostic error remains unknown, data from autopsy series spanning several
decades conservatively and consistently reveal error rates of 10% to 15%.”
The American Journal of Medicine published a

separate analytic review article in 2008
, concluding that diagnostic error occurs up to 15% of the time in most areas
of medicine. The authors further theorized that overconfidence often
accounts for at least some of the errors. These reports have reached a wide
audience in the laymen’s press as well. In 2015, the Washington Post published an article indicating that diagnostic errors affect 12 million adults each year. The
impacts of errors, as we see in the story above, don’t just involve the patient
but the patient’s families, too.

Though these statistics are shocking, it is almost impossible, from the
patient perspective, to look at them and subsequently be skeptical of everything a doctor says. After all, we are not only practically but also emotionally dependent on them: We want reassurance from our
physicians and we want definitive answers. As a patient, it is frustrating
to hear “It may or may not be cancer and we can’t be sure” or “I don’t know
how much longer she has left.” Indeed, when the path ahead of us is no
longer clear, we turn to physicians for answers because of their
experience. We want them to be the kinds of people none of us can
be — always right, always knowledgeable, always calm and composed. But they
are fallible, despite the impossibly difficult and long road they’ve
traversed.

And what can we as physicians take away from this? Doctors want to be
the kinds of people their patients expect them to be. But the statistics
of medical errors are the reminders of how impossible that is; how many years of studying and
experience are necessary even in order to be competent; how difficult,
despite the many exams we take and pass, it is to apply knowledge
appropriately. Not only are we fallible, but the science we rely on is not
always helpful either. Indeed, the best studies are useful merely for inferring what will
probably happen — they do not tell us definitively what will happen to the
patient in front of us. Moreover,

scientific evidence does not exist
for every treatment in every situation or every diagnosis in every
situation. Once again in medicine,

our ideal does not match with the real
, and our preconceived notions are sometimes shattered in moments of frustration
and uncertainty. Perfection is unattainable, but we must
constantly seek it out, always aware of how out-of-reach it lies.

When patients and their families now ask me questions about prognosis or
treatment I always preface what I say with: “Nothing is 100% in medicine.”
Though I will be wrong again in my career and will, hopefully, learn from
my mistakes, I never want to give a false impression. We often tend to ignore uncertainty or wish it away, but we must always remind
ourselves, whether as patients or doctors, that no doctor and no science is perfect.

CPR in the Hospital, Part 2

With what strife and pains we come into the world we know not, but ’tis commonly no easy matter to get out of it.

—Sir Thomas Browne,

Religio Medici

I wasn’t the first to arrive in her room. The resident had already started the code, and nurses, physicians, and medical students crowded around her bed,
performing CPR. The patient, a woman in her sixties, bore the physical scars of many life-saving interventions for deadly issues ranging from heart attacks to strokes to blood clots in her lungs. Six different IV bags with
medications hung on poles on either side of her bed. A tube stuck out from her neck and was connected to a breathing machine. Otolaryngologists (specialists in conditions of the nose, ear, and throat) created a tracheotomy for her months ago, cutting an opening through her neck because she
could not breathe properly through her mouth.

This was all I knew when I walked up to her bed, where ten physicians and nurses ran through the protocol necessary for restarting the patient’s heart. In
addition to defibrillation to
shock the heart back into rhythm, physicians give epinephrine to augment the effects of CPR.
Epinephrine raises blood pressure by constricting blood vessels, thus increasing the flow of blood into the brain and the heart. And, it binds to beta-1
receptors in the heart, improving the heart’s ability to contract.

A well-run protocol, or code, has a rhythm: Epinephrine is given every 3 to 5 minutes, chest compressions are performed thirty times for every two breaths, the heart is
shocked at the stop of compressions, and then we start over from the beginning. If there is a competent leader, then despite the chaos of human bodies crowding around the spectacle of death, opening drawers for medications, and
thumping on the patient’s chest, there is still order, a pattern, a method, a purpose.

Wikimedia Commons

When the resident doing chest compressions tired out, she shoved me to take her place the next time around. Chest compressions are intense, both
emotionally and physically, and one tires easily. So we cycle in and out — we compress for as long as our bodies allow and then make way for a colleague
who is next in line. I stepped up and began my compressions. The compressor must replicate the beat of the patient’s heart. If you go too fast, the heart
does not have time to fill and you don’t pump blood to the brain; too slow, and the brain is deprived of oxygen and your compressions are useless.

The patient’s eyes looked up at me as I pounded my palms onto her sternum rhythmically and her whole body shook. Still open, a thin glassy film covered her eyes, clouding the stuff of life that normally emanates from a human’s gaze. Feeling uneasy as the object of her empty stare, I looked up at the
TV: two pop singers were apparently at war on Twitter.

At some point — I can’t remember how early or late in the process this occurred — the patient seemed to gasp for air. She growled and gurgled, desperately
reaching for the elemental gas which we take for granted every time we inhale. This may have been her agonal breathing, a process that some experience on their way to death. The late Dr. Sherwin Nuland, a surgeon and writer, described this in his book How We Die: “The adjective agonal is used by clinicians
to describe the visible events that take place when life is in the act of extricating itself from protoplasm too compromised to sustain it any longer.” He
continues,

The apparent struggles of the agonal moments are like some violent outburst of protest arising deep in the primitive unconscious, raging against the
too-hasty departure of the spirit; no matter its preparation by even months of antecedent illness, the body often seems reluctant to agree to the divorce.
In the ultimate agonal moments, the rapid onset of final oblivion is accompanied by the cessation of breathing or by a short series of great heaving
gasps…. (p. 122)

 
Indeed, this is what the patient seemed to be experiencing. But was it? One resident tore open a drawer, found a thin, long, hollow tube and connected it
to the suction machine on the wall. Perhaps, he theorized, the patient had a mucus plug in her airway. In patients with tracheotomies,

the air bypasses the mouth which normally cleans and moistens the air we breathe
. In response, the patient’s body produces more mucus, which accumulates and blocks the flow of oxygen into the lungs. This could be an easily reversible
cause of the patient’s sudden deterioration.

The resident pushed the suctioning tube into the patient’s trachea while a nurse called the otolaryngologists who had placed the tracheotomy and were
better trained to deal with it. The resident retrieved small bits of mucus out of the patient’s airway, but we still needed to continue CPR. Eventually,
after many attempts to revive the patient, the attending physician looked at the clock and, realizing it had been 25 minutes since the code started, asked:
“Does anyone have any other ideas as to how we can save this patient?” Met with silence, he nearly declared the time of death to be 3:32 in the afternoon.
But the otolaryngologist shouted that he had finally gotten something. A long, viscous, and yellow-brown piece of mucus shot up into the suction tube and
the patient gasped for air. Her heart began to beat appropriately again; her respirations normalized. Within five minutes she was back to her old self
again, sick, yet alive and aware, conversant via hand motions and mouthing of words. She could now let us know that she existed. The glassy film retreated
from her eyes as she was pulled back from death.

This is an uncommon circumstance. In

a study in The New England Journal of Medicine in 2009
, researchers studied Medicare patients 65 years of age or older who underwent CPR in U.S. hospitals from 1992 through 2005. They found that only 18.3 percent of
these patients survived to discharge. Over the course of this time “the proportion of in-hospital deaths preceded by CPR increased, whereas the proportion
of survivors discharged home after undergoing CPR decreased.” It seems that CPR has not gotten better, and the authors express “significant concern” that CPR has increased “during a time of more education and awareness about the limits of CPR in patients with advanced chronic illness and
life-threatening acute disease,” like the patient we revived.

And yet, who can argue with the results that day? I wrote in my last post on CPR that “we rightfully value human life above all
else and thus owe the patient every weapon in this battle. While the rapidity of the process may seem callous, it is essential in a last-ditch effort to
stave off eternal rest. After all, what if she had been revived?” In this patient’s case she was fortunate. Yes, she was still critically ill, but perhaps
this gave her more time to be with her husband, who had been visiting her for months. Maybe now she could have the conversations with her family about
whether she wanted CPR done in the future if her condition worsened (she and her husband eventually decided they didn’t want any further CPR measures — this
one experience was traumatic enough). Alternatively, perhaps this revival would change nothing about how she would use her time on this earth. It is not for
physicians to say how she ought to use her new-found days; it is only for physicians, when appropriate, to help her grasp them.