As per all these other posts…

Many of the case discussions involve disappointed and grieving family members of those that had a missed diagnosis. This is, of course, sad for the individual but is not reflective of the ED community as a whole. There is simply no impetus to write in and share a case in which rapid diagnosis was made and the patient did well. This is bias sampling which is common in anedotal reporting. As an emergency physician in Michigan, I can assure the public that AAA and Thoracic Dissection is part of every single lecture regarding heart disease and critical care ED medicine. There will always be missed diagnosis regarding virtually every chief complaint. It does not mean the physician community as a whole is uneducated or complacent. I had a man die in the ED who had this horrible disease and yet presented with resolved nausea/vomiting and had NO chest pain, NO abdominal pain and had a normal routine work-up including CXR. It can be tough to pick up and yes, doctors, it can be obvious and sometimes ignored. I don’t think Mrs. Ritter’s 67 million lawsuit is the kind of education that the medical industry embraces. That is simple hyperbole from a “Hollywood” mentality. That said, a loss is a loss, and we all deal with it in different ways.

Grand Rapids Emergency Physician. 20 shifts a month, 20 years and still going.

A side comment… Working one ED shift a month does not make one an “Emergency Physician” it makes one a physician that works in an emergency room… and the repeated use of the “F” word does not engender the respect we physicians seek to earn from our patient population.

Thank you for your comments and your well wishes. Today (3/17) is the 4 year anniversary of my Ross Procedure. I had my annual follow up about 2 months ago and both valves are functioning perfectly and my slightly dilated aortic root (3.7cm) has not changed in 2 years. I realize that dissections are difficult to diagnose because the symptoms can mimic so many other problems. That’s why I think that when someone enters the ER with chest pain a simple list of questions may shed some light on whether or not this person may be at risk of aortic dissection. Since many cases of aortic dissecton accompany patients with bicuspid aortic valves, Marfans, or other connective tissue disease…asking them questions about their family history may be the “needle in the haystack” that doctors are looking for. If they have a family history of family members dying of “heart attacks” at a relatively young age that would be a major red flag. Also listening to the patient when they explain their symptoms may help doctors differentiate possible causes for those symptoms. I think part of the problem is that since ER docs don’t experience many patients arriving with aortic dissections it’s too easy to lump their symptoms with other, more common health issues that they see much more frequently. But one thing I’ve noticed in most of the testimonials here from dissection patients or their family members is that with treatment the symptoms did not subside…another red flag. That’s why I learned early on that I (or my family) had to be my own “patient advocate” and not feel too intimidated to question a doctor’s diagnosis and/or treatment. Some doctors don’t appreciate this, but when I’m sick and feel like there may something seriously wrong the last thing I’m worried about is bruising someone’s ego. I’d rather be wrong and apologize to the doctor later than be right but kept my mouth shut with catastrophic results.

I have a lot of respect for physicians and their dedication to helping people, but like other doctors have said here they are only human and will occasionally miss a diagnosis. That is where a well informed patient may make a difference in helping the doctor narrow down the possible causes for the symptoms they present when they arrive at the ER (or doctor’s office). This is assuming the doctor is willing to listen to the patient and take them seriously.

My family physician missed the fact that I had endocarditis for 4 months. The first time I went to him I filled out the medical history sheet that I assume goes in the patient’s chart. I wrote on mine that I was born with a VSD (large) that had not been repaired because I had been generally asymptomatic. At age 17 they detected that the shrinking (but not closed) VSD was causing aortic valve prolapse and aortic insufficiency. Fast forward to 2003 and I get a nasty case of bronchitis I can’t shake. After a few rounds of antibiotics, then steroids accompanied by M-Clear cough syrup we finally beat the bronchitis. But then I presented over the next few months with a low grade fever, night sweats that became increasingly worse, prostititis, swollen hands and feet, painful joints, and eventually a dull pain between my shoulder blades. I was going downhill fast. About 3-4 weeks before I was diagnosed with IE I told him that I was worried that I might have it. He dismissed me and said you don’t even have a murmur. I guess a (now) small VSD and moderate aortic insufficiency can not be detected by the “average” doctor when he/she listens to your heart. I kept going downhill and I finally insisted that he run a blood culture on me. The culture was performed on a Friday afternoon and he called me on Sunday morning to let me know that it had already come back positive and was going to call me in some Cipro 750mg. On Monday I was so ill I called him back and insisted that I get an echo. The echo was perfomed Tuesday afternoon and I was admitted to the hospital Tuesday afternoon with infectious endocarditis. After 7 weeks of an IV regimine of Rocephin 2gm daily I had a cardiology consult (which my doctor didn’t think I needed) where I found out that I needed to have by aortic valve replaced and my VSD repaired. BTW I had a Ross Procedure at Duke.

OK doctors…was this a case of a difficult diagnosis that happened to be missed by my doctor or a case of malpractice? Remember that I filled out the patient history sheet stating that I had AI and a VSD. I reminded him of that and he said I didn’t have a murmur. I told him that after researching the symptoms of endocarditis I had all of the classic symptoms. I had to prod him to do a blood culture (even though my white count was higher every time it was taken) and an echo.

Guess what…I didn’t sue him. Not because I didn’t think he was negligent, but because I thought he was trying to help me the best he could. IMO his 2 main mistakes were not reviewing my past medical history (or not connecting that history with being at a higher risk of contracting IE) and NOT LISTENING TO THE PATIENT. When a complete stranger comes into the ER who do you think knows their body better…you who have known the patient for 2 minutes or the patient and/or family member? I honestly think that if doctors would actually listen to their patients better it might make it easier to make a correct diagnosis. I realize not all patients/family would be intelligent advocates for themselves, but that’s part of being a good doctor…having a sense for which patients can help you diagnosis their problem and which ones can’t.

Sorry for the thread jack on dissections. BTW…IMO I think dissections are much more common than most people think, but unless an autopsy is performed it is often considered a heart attack if the patient dies before being diagnosed.

And even if it was $1000 extra, if you the consumer is so smart about your diagnosis, then ask for a CT and offer to pay for it. What, you’d pay $1000 a year for cell phone use but not for a CT that could save your life??? I think there should be a separate line in the ED where you can swipe your credit card and order whatever tests you think you need at the rates billed to the insurance co. A lab tech could come in and draw the blood and another tech does the CT or whatever (no, your doctor doesn’t usually do those test like they do on TV). then you could sit down with your harried ED MD and present the results. Pay up or shut up america.

He has said it all.

The bitter whining and baying for physicians’ blood will continue, but that is the ugly side of humanity.

Australian Anaesthetist.