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.

A Tour of the Intensive Care Unit (ICU)

I have a rendezvous with Death
At some disputed barricade,
When Spring comes back with rustling shade
And apple-blossoms fill the air—
I have a rendezvous with Death
When Spring brings back blue days and fair.

It may be he shall take my hand
And lead me into his dark land
And close my eyes and quench my breath—
It may be I shall pass him still.
I have a rendezvous with Death
On some scarred slope of battered hill,
When Spring comes round again this year
And the first meadow-flowers appear.

God knows ’twere better to be deep
Pillowed in silk and scented down,
Where Love throbs out in blissful sleep,
Pulse nigh to pulse, and breath to breath,
Where hushed awakenings are dear …
But I’ve a rendezvous with Death
At midnight in some flaming town,
When Spring trips north again this year,
And I to my pledged word am true,
I shall not fail that rendezvous.

—Alan Seeger, I Have a Rendezvous with Death

The Intensive Care Unit is an uncomfortable place. It is where the sickest patients in
the hospital reside. Because many of the patients require emergency medical interventions or close monitoring, the layout resembles that of the emergency department (ED). Patient rooms encircle a nurse’s station where computers sit on a long table. As in the ED, each room is filled with machines
projecting vital signs, EKG tracings, IV fluid rates, and other information towards the physicians and nurses. And the nurses in “the unit” (as it’s
commonly referred to) are always active, checking in on patients throughout the day and night.

There are many different types of intensive care units: some for patients with heart issues (cardiac ICU), others for patients with neurological issues
(neuro ICU), pulmonary or general medical issues (medical ICU), surgical issues (surgical ICU) and cancers (oncology ICU). What we see in each unit,
however, is equally disturbing. And what follows are the some of the things one might see (and which I have seen) in different ICUs over the course of a
day.

Image via Shutterstock

In the neuro critical care unit, one patient lies unconscious with a massive and deadly brain bleed. In another bed across the room, a patient with a rapidly expanding
brain tumor cries out in searing pain from a headache. In the cardiac intensive care unit, a patient, hours after receiving a ventricular assist device (VAD), a device which helps the heart’s ventricles pump out
blood after being weakened by disease, receives chest compressions from a nurse as he goes into cardiac arrest. Another unconscious patient in the far
corner of the room is on ECMO, or extracorporeal membrane oxygenation, after
having massive heart and lung failure. ECMO takes blood out of the venous system, oxygenates it in a machine and then pumps it back into the arterial
system, thus bypassing the heart and the lungs. In the normal circulatory system, blood goes from the veins into the right side of the heart and
subsequently to the lungs where it is oxygenated, flows to the left side of the heart and is pumped into circulation to nourish the body’s tissues. ECMO
temporarily maintains circulation until the patient’s heart and lungs can function on their own.

In the oncology unit, a middle-aged cachetic patient lies face-up in the bed, staring at the ceiling while fungal and bacterial infections cause his blood
pressure to drop and heart rate to increase. Despite the medications used to prevent these infections in cancer patients with very low white blood cell
counts, sometimes the microbes sneak by. And because chemotherapy used to treat cancer destroys white blood cells, the cancer patient has nothing left with
which to fight off the infection. Even the most minor bacterial invasion can be fatal for these patients, as it eventually was for him. Meanwhile, in the next room, another
patient had just passed away and her family crowded around her bed sobbing and mourning their loss while holding the expired patient’s
hand, hoping for the return of warmth.

Unusual sounds percolate from room to room in these dank areas of the hospital. Most noticeably, IV poles beep
constantly as they run out of their fluids or medications. Cardiac monitors sound alarms as patient heart rates dip too low, rise above a normal level, or register abnormal
rhythms. Some patients moan and scream, losing all sense of time and of themselves. Or, perhaps they curse and threaten nurses while withdrawing from
alcohol. Others vomit and pass gas. Some patients demand the impossible: “get me out of here!” or “leave me alone!” Sometimes patients need to be strapped
down to the bed because they pull out their IVs as they wail and moan and thrash about. During the day, minimal light shines into the unit and it is
tainted by the sickness and suffering which pollute the air and tint the windows. Foul smells, which I wrote about here, are most potent in the ICU. Many ICU patients,
though washed by nurses, have not bathed in weeks. The stench of sweat, stool, and blood permeates the unit when nurses change patients’ diapers,
suck accumulating mucous out of patients’ mouths, and clean up blood-stained sheets.

And if you think it’s bad for providers, imagine what patients experience. The ICU must feel like a kind of hell on earth. Sleep is rare when your
neighbors expectorate, choke, vomit, and shout, and nurses and physicians constantly wake you up, draw blood from your veins, and examine you to ensure your
mind still functions correctly. Some patients can’t eat or drink because they need surgery (it is safer to put patients under anesthesia for surgery when
they have not eaten because food will not come up from the stomach and choke the patient or travel into the lungs while they are unconscious) and so they go to bed hungry and
thirsty. A patient may even go to sleep not knowing whether he or she will wake in the morning. You may be one of those who
has a rendezvous with death tomorrow; you may be one of those who survives; you may hang on by a thread for weeks. Who would ever want to end up in an
ICU?

And yet, it is in the ICU that patients receive the most fastidious care. Nurses watch over only one or two patients and thus can keep a close eye on them.
Physicians trained in the art of emergency procedures, like intubation, are always around
and watchful. Nobody will be more attentive to your medical needs than an ICU team, which monitors every sign of life you emit: breaths, heartbeats,
skin color, blood pressure, electrolyte levels, blood counts, infectious disease cultures from your urine to your spinal fluid. The advantage of being in
the ICU is that you receive the care that you need even if it is in a frightening environment. I hope I never have to be there, but if I am severely ill at
some point in my life, the ICU is the place I would choose to be.

PCP Overdose in the Emergency Department

There was a crowd of security guards, physicians, and nurses in an ED room. The patient inside squirmed and writhed on the stretcher while sweating
profusely, soaking his clothing and the hospital bed. Though slender
and slightly cachectic, the patient had fought off the security
entourage multiple times, like a snake slipping from their grasp,
violently twisting and
turning his body.
As he struggled, a nurse tore off the sleeve of the patient’s dark blue jumpsuit in order to get IV
access and administer medications. The 26-year-old man kept his eyes wide open and stared at the ceiling, which made it easy for me to see his
tremendously large and dilated pupils, empty and frightening at once. Seven security guards held him down when the nurse started the IV.

All this went on for about an hour, and as the time passed the monitor above the patient’s bed, which projected his temperature, blood pressure,
and heart rate, changed. The temperature rose: 99…100…101…102…. The heart rate went up to 120 (a heart rate above 100 is considered fast and is called tachycardia). The blood pressure, too, rose
to 160/100 (normal is approximately 120/80). And the patient continued to sweat and writhe. As he exerted himself, his cells produced molecules necessary
for energy, a process which generates heat and increases heart rate and blood pressure.

The patient was experiencing a PCP, or Phencyclidine, overdose. PCP is a drug that was developed in the early twentieth century as an anesthetic. However, the drug also caused
delusions, anxiety, and agitation and was eventually discontinued because of these side effects. In the 1960s, many drug addicts used it illegally in pill
and smoke form. Because PCP acts partially among dopamine receptors in the brain it can cause both
euphoric and, sometimes, psychotic and violent behavior. On medical licensing exams we are expected to recognize the typical PCP symptoms: violent behavior, dilated pupils, profuse sweating and
tachycardia. Additionally, the drug can cause seizures, hyperthermia (very high body temperatures), severe hypertension or high blood pressure – which can
damage the eyes, kidney, and brain as well as other organs – and rhabdomyolysis,
the breakdown of muscle, which can cause further kidney damage. Unfortunately, no medication exists to reverse the drug once it’s been ingested and
treament primarily targets only a patient’s symptoms.

The resident started treating this particular patient with a type of benzodiazepine, a sedative drug
that acts on receptors in the brain to inhibit anxiety and agitation. This class of medications is frequently used for patients who have prolonged
seizures, severe anxiety, or difficulty sleeping. After multiple doses of benzodiazepines over the course of the hour, as well as IV fluids to counteract
possible rhabdomyolysis, the patient continued to fight and his temperature continued to rise. It was almost as if he had not been given any medication at
all.

At this point, the only option was to use drugs to knock the patient out completely, or paralyze him, so that he would stop struggling and his vital signs would
normalize. To ensure the paralytic drugs do not prevent the patient from breathing, a tube is placed down his throat, keeping the airway
open. The resident injected the paralytic into the IV, and once it took effect he
used a glidescope to pry open the patient’s throat in order to visualize
the airway. Then, he stuck a short plastic tube down into the trachea. The hollow tube allows oxygen to pass into the trachea thus acting as the patient’s
mouth and throat. The tube is then connected to a ventilator that pumps air into the lungs and thus keeps the patient oxygenated. A great video
of this procedure with narration is available here.

This last ditch effort worked. Over the next few hours, the patient’s temperature and blood pressure dropped and he avoided the dangerous sequelae of his
toxic ingestion. Although curious to see what would happen to him next, my rotation ended before the patient was admitted to the hospital and I went home
to sleep off the overnight shift.