Saturday, September 04, 2010

Massive Clusterfuck in 3...2...

Dear Doctor Mellowly:

I understand that things get busy in the ED at around nine on a Friday night. I also understand that the availability of Urdu translators is limited in this area.

Still, when you have a patient in her late eighties, with family members who can translate for you, present at your ED with excruciating neck pain, quadriparesis (weakness in all four limbs), a visible contusion on her head and one on her neck, and a history of fractures secondary to osteopenia (weakness of the bones), who fell at home, it might behoove you to do a c-spine (neck) X-ray.

Yes, yes, I know. The radiology department is busy with drunks and gunshot wounds. Still, consider doing an actual X-ray and not just a head CT. Because, you see, that would prevent you from sending your itty-bitty, fragile patient out to Sunnydale's neuro critical care unit in the middle of the night with a broken neck rather than with a stroke.

At least you were nice enough to give her an ice pack to relieve the pain from the hangman's fracture* that she had.

When she showed up in the Sunnydale NCCU, our nurse was bright enough to connect the weakness in all four limbs with the neck pain (as you failed to do) and order a c-spine. Which showed the chunk of bone floating freely in MeeMaw's spinal column. She also ordered a chest X-ray, going by that gut feeling that we nurses sometimes have, and discovered a high thoracic fracture as well.

MeeMaw, surprisingly, is fine. I transferred her this morning to the surgical CCU, where they put her in a pair of tongs that provided a few pounds of traction. I had given her ten of Decadron IV shortly before that, so the feeling in her hands and feet was beginning to come back when I left today. She's damned lucky that in the move from the ED bed to the ambulance cot, the fracture didn't take her life. And somehow, she managed not to be paralyzed over the forty miles of bumpy roads she had to ride to Sunnydale.

Seriously, dude? This was a colossal fuckup; a sentinel, never-event. And I put all the wheels in motion, along with my night-shift counterpart, to nail your ass to the wall. In fact, I recommended to my boss that he not call your hospital's risk management department to clue them in to what had happened: it was that serious.

I don't know if you were drunk on-shift (again) or what. What I *do* know is that, after misdiagnosing a rotator cuff tear, cervical myelopathy, appendicitis, and a broken neck as things that need to come to *my* unit as neurological emergencies, you deserve to be spanked.

*A "hangman's fracture" is a fracture of the part of the spine that connects your head to your neck. The usual mortality for such a critter is around 60%. As in immediate mortality; the figure rises if you include misdiagnoses from folks like Dr. Mellowly.


RehabNurse said...

Oh, lordy!

I think of this all the time...especially when our docs INSIST that we do x, y and z for no reason, except to x-ray patients multiple times when it's not needed.

Geez... are they even thinking?

woolywoman said...

Do you need a spare hammer for that nail? I'd be happy to hand you one. Thank the whoevers that she's ok.

Anonymous said...

This is such a crazy story that I felt it necessary to create a post on my blog solely so I could link to your post. I cannot believe that doctor could miss something this bad!!

Dr. Alice said...


Sorry, that's all I got. I do not consider myself a diagnostic genius, but. Who would NOT have thought of this possibility?

bobbie said...

Jeezly crow!!!!!!!!!!!

Definitely needs to be reported!!!!

Unknown said...

. . . She's damned lucky that in the move from the ED bed to the ambulance cot, the fracture didn't take her life. And somehow, she managed not to be paralyzed over the forty miles of bumpy roads she had to ride to Sunnydale. . .

From my experience, escaping a harrowing transport relatively unscathed is the only surprising part of this story. The severity of each mistake and oversight, is a daily occurrence at the only Level-One trauma center where I work in northern New England.

Brian said...

I'm glad to hear you're reporting this.

The thing I don't get is why it takes such a huge screwup before somebody gets punished. If he's come into work drunk before, shouldn't he have been fired the very first time? What is it about the medical culture that lets crappy practitioners stick around to put more people in danger?

Seriously, if you've got any insight I'd really like to read it. This seems like one of those things they won't teach us in school.

messymimi said...

Merciful heaven protect us from those who are supposed to protect us when they are major clueless like this.

Nurse Jobs said...

This is exactly why nurse jobs and the medical field in general is so handle this level of responsibility with patients who are in pain, in life or death situations...Well, and as you point out, some handle it much better than others! How it would suck to work with someone like THAT guy. I'm so glad MeeMaw was okay.

Molly said...

Holy crap. That's...enormously disturbing. I know people make mistakes, but I'm not a doctor, nurse, tech, or even a hospital janitor and even I figured it in a few lines of text.