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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