Missed diagnosis in the ER, and the need to look

by 911Doc, MD

WNL is doctor shorthand for “within normal limits”. Saves a bunch of time when checking the boxes on the physical exam. The temptation is to write “WNL” whenever possible, and, therefore, it often ends up meaning “We Never Looked”.

A homeless gentleman presented to my ER a few months ago. He had been hit in the head with a beer bottle. He had a suturable laceration to his scalp to prove it. He was in a lot of pain, but it was his neck (not his forehead) that hurt him.

We spent hours with this guy, we x-ray’ed and CT scanned and MRI’ed and to no avail. I pulled in a few other docs to help. We had zero to go on except muscle spasm or torticollis and that’s what we ended up calling it.

Two days later a friend, also an ER doc, came up to me and said, “Hey, did you take care of homeless guy X the other day?” This question will stop any ER doc in his tracks because the next thing you are about to hear is inevitably bad news.

“Yes,” I said, “Why, what happened?”

“He came back last night, altered, and with a fever. I tapped him and he had meningitis. He died.”

Damn. I never looked. The case went before the hospital quality control committee and I was found blameless and there was never a law suit. Cold comfort. But even with the retrospectoscope, I would not have done anything differently. No fever, no headache, no alteration in mental status upon initial presentation … simply a hit on the head with a beer bottle and a laceration.

Occam’s razor failed me here, and ultimately, this is, in large part, why getting care in the ER is expensive. It may be true that your “heartburn” is simply that, but could it possibly be your impending heart attack? Yes, it could, and I am going to look.

911Doc is an emergency physician who blogs at M.D.O.D.

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    “It may be true that your “heartburn” is simply that, but could it possibly be your impending heart attack? Yes, it could, and I am going to look.”

    So is that why every time I go near a big hospital with lots of very expensive equipment, they keep me for three days running lots of tests? I think I’ll go to a small walk-in clinic with a nurse practitioner next time.

  • Doc99

    Is it me or are ED’s missing fractures at a higher rate than in days gone by? Spent 7 hrs in the ED of a Major Metropolitan Medical Center with a family member who fell two flights onto a concrete floor and we thought we escaped with just soft tissue injury. Two days later – fractured wrist AND hand. My bad luck or the sign of something more systemic?

  • Max

    Good points but as you say, no fever, etc and only neck pain. Did he have nuchal rigidity? You probably didn’t even have a reason to check. I think overall you did a good job with this patient and it’s definitely not your fault.

  • mark

    It sometimes takes a few days for small fxs to show up on an xray. At first you can’t really tell if it’s soft tissue only or not. That is very normal.

  • moishe

    I’m a Emt in a local corp in ny where most patient are either known or know someone in the corp I think the electronic x-ray reading system is the problem it just not the right amount of resolution and contrast. and unless a orthopedic with experience looks at the x-ray and knows what he is looking for a resident radiologist might miss it.

  • Anon EM doc

    Did he have a fever? If not, you had little reason to suspect any cause for neck pain other than his traumatic injury. Don’t let lawyers tell you how to practice.

  • http://www.docsontheweb.blogspot.com 911doc

    thanks for the comments everyone. thanks to kevinmd.

  • Dr. G

    He could of been struck by lightning immediately after leaving the ER as well. There are no absolutes in medicine. You do you best, but sometimes bad things happen. How far down the slippery slope of removing all doubt must we slide?

  • @Meryl333

    Machines are often used to uncover what we are already looking for. When I came in to ER, I had chest pains on and off for a month. Tried to tell them the background of trauma/stress etc, but they were looking for artery problems. 5 stents later, the pain persisted and I was blown away. It wasn’t until I saw an experienced expert in Chinese Pulse diagnostics that the problems were uncovered and resolved (not with pharm, but with herbs and a long term solution that Western medicine has no patience for).

  • Rowan58

    My 66 year old brother was seen in the local ED on a Friday morning, his PCMD was closed due to air conditioning problems, c/o n&v, dizziness & mild diarrhea x 5 days. Due to an increased number of “vertigo” cases seen in the ED this week this became his dx. Sunday he was much worse & in bed all day. Another trip to the same ED, same MD. Vertigo! Ran some minor labs that were normal. Gave 5mg IV Valium, sent home w/rx’s for diazepem, meclazine, antibiotic & OTC antihistamine. When questioned by family that maybe something might be going on the ED MD stated “I can absolutely guarantee that nothing else is going on. This is vertigo because I’ve seen it all week”. My brother was unresponsive by Wednesday after admission to another hospital. He had a crainotomy the following Monday to remove 2 lesions in his brain. The total missed dx did not bother me as much as the outburst from this physician when questioned, along with the use of “absolutely” & guarantee”. I am a Critical Care RN & there are no absolutes when it comes to the human body or health care. My many years in critical care has taught me that the second you assume something, your patient will prove you wrong. Arrogance & medical science have a disastrous effect on everyone. This is not just an observation of physicians because I’ve experienced this deadly combination in all areas of our health care system. I believe adding system to health care has had detrimental effects. In caring for our patients we have to remember that we are not working a system but caring for the people who place their lives in our care, not a system. I have spent the last few weeks assuring my family that not all doctors are “quacks” and the majority are very well educated & on top of their game. It has been a struggle to keep everyone’s opinion & faith in what has become a very medically dependent situation. My brother has stage 4 lung adenocarcinoma w/mets to the brain. No prior symptoms before. He was just a very happy retired gentleman enjoying his yard work, hunting, and working in his new shed. So this becomes one of the ugly stories that floods our communities and places fear & mistrust in health care. I’m not picking on MD’s solely here because I had a few rounds w/some RN’s also. That’s for another place. I have not practiced nursing for the past few years. The system wore me down.

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