Mickey followed me into Ronnie’s cramped quarters, sat down, and began asking the usual questions about what happened when. Ronnie mentioned that she had called a doctor late Friday, and he hadn’t seemed too concerned. Puzzled, since a story of fluid leakage and contractions at 31 weeks is alarming to anyone who practices obstetrics, I interjected, “Who did you talk to? Was it Dr. W?” — one of the doctors with whom I share obstetric call responsibilities — “Friday afternoon?”
“No, it was Friday night, and it was another doctor.”
That stopped my questions. I maintained my calm exterior and wrote a note in her chart while Mickey continued her inquiry, but my insides were churning. She had talked to me Friday night, and I had somehow missed the diagnosis. Hers was one of several calls that came in between 10:30 and midnight, and I was having a maddeningly difficult time recalling our conversation. It took me several hours to put it together as best as I could, but I did recall that she had told me she felt a constant discomfort in her lower abdomen that would get worse “for a couple of minutes” and then diminish. I made sure she clarified that she meant minutes and not 40 to 60 seconds, which would suggest early labor. After a short conversation, her descriptions satisfied me that she wasn’t in labor, and I told her to drink plenty of fluids and call me if her symptoms worsened.
This was malpractice. When an obstetric practitioner gets a phone call from a pregnant patient, there are four symptoms that the conversation must cover: contractions, bleeding, fetal movement, and leakage of fluid. Residency faculty drill these four elements into every resident’s head. The malpractice lawyers also know them and look for them in every documented phone contact in the records they review. I somehow forgot to talk about Ronnie’s fluid, and she didn’t mention it to me. I called our answering service and asked what Ronnie had told them when she asked them to call me, and their records showed that she complained of pain and “losing control of my urine.” The service must not have relayed that second part; either that or I am losing my mind.
So, thanks to me, Ronnie walked around for 36 hours with her membranes ruptured nine weeks before her due date. If I had sent her in for evaluation Friday night, we could have started antibiotics to help prevent infection and given her two corticosteroid shots to help her baby’s lungs mature. Instead, Ronnie was coming in now in early labor. Her temperature crept up to 100.1 degrees, which was enough for Mickey to decide that we should not delay delivery. Since Mickey was managing the situation, I wished everyone well and went home.
I have made mistakes before. When I was a second-year resident, I was on call one night when I had already admitted four patients to the hospital and therefore had not slept at all. It was 4:00 a.m., and an ambulance brought in a sixtyish-year-old, cheerful, obese man with an “asthma attack.” We treated him with asthma medications and he improved, but I recognized that it is not common for someone who has never developed asthma to get his first attack in his 60s. I ordered a chest X-ray. I looked at it. His heart was big, and the blood vessels to the lungs showed excessive engorgement. I had found the sort of trouble I was looking for; the man had congestive heart failure (CHF), a condition where the heart does not contract with enough force to push forward all of the blood that comes to it, and therefore the circulation backs up into the lungs, filling them with fluid. But my body had such a strong desire to sleep and my fatigue had clouded my judgment just enough that I was able to create a new interpretation and convince myself that it was correct: the X-ray showed CHF, but his clinical course was consistent with asthma, so therefore the X-ray was wrong and I could send him home. Much to the patient’s delight, he went home and I went to sleep.
When I awoke 90 minutes later, my senses had returned. I got a well-rested resident to call him and admit him. The patient felt better than he had in days, but he did come back, which was a good thing because he had also had a heart attack. Later that morning, I went to Dan, our residency director, and offered to take whatever punishment he felt was appropriate and wondered if I should rethink my career choice. I was being too hard on myself, of course, and he pointed out that I had found my mistake, fixed it, and done the appropriate introspection afterward. The patient did well and, ironically, left the hospital thinking I was a great doctor.
I was a bit less lucky with another patient, a 22-year-old-blonde-former-cheerleader-type who came into my office a couple of years ago with a bladder infection, which I confirmed by examining her urine before going in to see her. Early in training, we learn to assume that a woman of child-bearing age who comes to a doctor for any reason is pregnant until proven otherwise. I asked her if she was using birth-control pills, and she said no. She then brought up that she and her fiancé were getting married that weekend and going to Maui for their honeymoon. My wife and I had spent our honeymoon there, so we talked some about that while I examined her back and abdomen. I never returned to the topic of her contraception. I prescribed her the standard three-day regimen of a sulfa drug and wished her the best.
Two days later, two days before her wedding, she called me to tell me, in a voice boiling over with hatred, that she was pregnant. “I knew I might be, but you never asked,” she sneered. The problem: sulfa drugs in high doses cause fetal toxicity in rats. Reports of such toxicity in humans do not exist, but the findings in rats have led the FDA to place sulfa drugs in Category C for pregnancy, which means they should not be used unless the physician judges the benefits to outweigh the risks. She proceeded with her verbal assault, accusing me of lacking professionalism and ruining her wedding. She would make sure that none of her family or friends would ever come to me for care because of my incompetence.