medical error

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Tragically Wrong: When Good Early Pregnancies Are Misdiagnosed As Bad

An ultrasound of a pregnancy at six-and-a-half weeks (meaning that it was done two-and-a-half weeks after the woman's missed period.) The pregnancy sac  is outlined by four short arrows within the uterus and the embryo is within the pregnancy sac. (Courtesy P. Doubillet)

An ultrasound scan of a normal pregnancy at six-and-a-half weeks (meaning that it was done two-and-a-half weeks after the woman’s missed period.) The pregnancy sac is outlined by the four arrows and the embryo is within the pregnancy sac. (Courtesy P. Doubilet)

A beautiful, supremely talented young friend of our family recently fell victim to a terrible medical mistake. Newly married, she was having some pelvic pain and bleeding, and the doctor who saw her diagnosed a probable ectopic pregnancy — an embryo that develops outside the womb. Concerned that such pregnancies can turn life-threatening, the doctor prescribed the standard treatment: methotrexate, a drug used for chemotherapy and to help induce abortions.

When our friend returned to be checked a few days later, the imaging revealed that in fact, the pregnancy had not been ectopic; it was in place, in her uterus. But because she had taken the methotrexate, a known cause of birth defects, her pregnancy was doomed.  She soon miscarried. What may have been a perfectly healthy pregnancy had been ended by well-meant medical treatment.

I assumed her horrifying case was an exceedingly rare medical fluke — until now. A paper just out in the prestigious New England Journal of Medicine shows that such misdiagnosed pregnancies are part of a pattern — a pattern that needs to be changed. “Considerable evidence suggests that mistakes such as these are far from rare,” it says.

When I told our friend’s story to the paper’s lead author, Dr. Peter Doubilet, he responded that he knows of “dozens and dozens and dozens of similar cases that have come to lawsuits, and that’s probably the tip of the iceberg.” There is even a Facebook group, Misdiagnosed Ectopic, Given Methotrexate, run by a mother given methotrexate whose daughter was born with major birth defects.

The New England Journal of Medicine paper stems from a panel of international experts who resolved to change medical practice to stop such misdiagnoses. I spoke with Dr. Doubilet, who is senior vice chair of radiology at Brigham and Women’s Hospital and a professor of radiology at Harvard Medical School. Our conversation, lightly edited:

Before we get into the nuts and bolts of the problem, what’s the upshot for women of child-bearing age? What’s your message to them?

When a woman gets pregnant, a number of serious complications can occur early in pregnancy, including miscarriage or ectopic pregnancy. When a doctor diagnoses these problems within the first two to three weeks after her missed period, it’s very traumatic to the patient and it’s critically important that the woman and the doctor are confident that the diagnosis is correct, because the steps that will be taken would harm a normal pregnancy if one is present.

Dr. Peter Doubilet (Courtesy)

Dr. Peter Doubilet (Courtesy)

It’s become apparent over the past two to three years that errors in diagnosis of miscarriage and ectopic pregnancy occur more frequently than they should, and that’s why we put together a multi-specialty panel of expert doctors from radiology, obstetrics-gynecology and emergency medicine to come up with new, more stringent guidelines for diagnosing these complications, taking into account the most recent research on the subject.

And just to simplify, when a woman in very early pregnancy has been told that it appears that she has an ectopic pregnancy or a failed pregnancy, it would very rarely be overly risky — and often be wise — to wait a couple of days and be sure of the diagnosis before acting?

Yes. That’s a very important message. In 2010,  I, together with Dr. Carol Benson, wrote an editorial in The Journal of Ultrasound in Medicine entitled “First, do no harm to early pregnancies,” and that was the key message: Unless the doctor is sure that the woman has a miscarriage or an ectopic pregnancy, the doctor should err on the side of waiting, as long as the woman is stable and shows no signs of serious internal bleeding.

If the patient meets definite criteria for a miscarriage or ectopic pregnancy, there’s no reason to wait, but if there’s any degree of uncertainty, the prudent thing is to wait. Continue reading

Must-Read: The Tale Of A Surgery Gone Very, Very Bad

(Martin. Boyer/flickr)

The first hint that this story will not end well comes early, as writer Kerry O’Connell considers surgery for his dislocated left elbow and fractured forearm sustained after falling off a ladder in his driveway in Golden, Colorado.

In the current issue of Health Affairs, he writes:

…the surgeon said that in lieu of a plaster cast, which wouldn’t provide the flexibility my arm needed, he’d bolt a metal hinge device called an external fixator onto the outside of my arm. It would be held in place by three-inch bolts screwed through my arm and uninjured parts of my bones.

I had no idea what he was talking about. But he seemed knowledgeable and competent.

When he told me that if it were his arm he’d want the surgery done, I signed the consent form. I wanted a fully functioning left arm.

On my way out the door, I turned and asked my only relevant question of the day, “How many of these fixator things have you installed?” The surgeon gave a curious answer. They were fairly new, he said, but his practice group had installed three or four of them. I left without a second thought.

That’s when the trouble begins. And anyone considering surgery should read on and take notes. Continue reading

Anatomy Of A Misdiagnosis

Sarah G./flickr

Hopefully, a doctor out there will learn something from this.

Here, as part of the Institute for Healthcare Improvement’s Open School, Academic Advisor James Moses recounts the distressing story of a Lauren Mason, an 18-year-old college freshman with terrible pain on the left side of her face who was misdiagnosed by a reputable ENT specialist at a major Boston teaching hospital.

Dr. Moses interrupts his storytelling periodically with leading questions about Lauren’s care (for instance: “Has the case been centered on the patient thus far? Why or why not?” or “If you were Lauren’s ear, nose, and throat specialist, what else would you have said to Lauren’s mother? Would you apologize for the misdiagnosis?”) Here’s a snippet of Lauren’s saga:

During four hours in the office, she endures a long series of tests, including more for her balance and equilibrium. She also spends time in the Audiology Department and gets extensive hearing tests done.

Finally, the doctor diagnoses Lauren with a case of internal shingles in her ear canal. He explains that since she had chicken pox when she was little, she is susceptible to getting shingles. Lauren asks if he can see anything like shingles inside her ear. The doctor says no, but surmises that there was an outburst a few months ago and that the nerve damage was becoming evident now. He explains that it’s a disorder called postherpetic neuralgia and that she may also have trigeminal neuralgia, or unexplained pain that affects parts of the face. The doctor prescribes an anti-seizure medication (to help calm the nerves causing pain), an opiate to help manage the pain, and a stronger painkiller for especially difficult episodes. Lauren is instructed to take the pills three times per day.

The visit ends with the doctor telling Lauren that here is no guarantee the pain will ever go away…

Continue reading