KWC - Delay in diagnosis

-----Original Message-----
From: Chapman, Jocelyn
Sent: Thursday, March 17, 2011 9:38 PM
To: Autry, Meg
Subject: RE: Resident Feedback - one more thing...

I'm clearly obsessing about this. Please, don't share these words with others.

I feel terribly, I wish I were Catholic or something and could say some "hail mary's" and take away some of my guilt.

Which indicates that I need to admit more fault than I did in my first email.

Part of what was going on as well, I think, is that I was at the very end of 6 weeks of feeling insignificant, belittled, undervalued, treated like an intern or worse and I was pissed. I was really pissed. I was on my last day of service and couldn't wait to be done with that group. So, yeah, I did think we should go straight to the OR at the 2nd presentation. There was a lot going on but when I realized who it was it was a no brainer. But instead of leading the attending down the right road, I sat back, made a pitiful attempt at advocating a plan for the OR and when the attending didn't seem inclined to take her, I didn't fight it. And I thought, well, fuck it, its her license, not mine.

WHICH IS A TERRIBLE THING TO THINK! Me being mad at that group of doctors doesn't mean that I can take it out on patients. I invest a lot of time and energy into relationships with people who care about me and who want me to succeed. But if I get the sense that someone doesn't really give a shit, I sort of just check out and exit the relationship. I'll confront people and hammer out the differences if I care about them and know they're invested in me. But this is all sort of missing the point - the patient is supposed to be the point, not my fragile ego.

So I feel like shit. I feel like a horrible doctor. It won't happen again - I'll certainly use this cautionary tale as a learning opportunity.

-jocelyn
-----Original Message-----
From: Chapman, Jocelyn
Sent: Thu 3/17/2011 7:10 PM
To: Autry, Meg
Subject: RE: Resident Feedback

jesus. Well, I guess now I know what its like to be a defendant in a malpractice trial.

If I were the resident they described then I certainly wouldn't promote me from residency. It is a gross understatement to say that I have a different perspective on the course of events.

I don't know if you're interested in the blow-by-blow but I'll just say the following:
-I definitely was not notified about the CT findings at first presentation. The ED thought appy likely and wanted to do CT. Radiology wouldn't b/c she was pregnant. I was consulted. One thing I found frustrating in this work-up is that I feel I'm really quite good at pelvic ultrasounds and I really like to do them. I never really figured out how to get their ED ultrasound to produce appropriate pictures. The penetration was poor or the machine was old. It always bothered me a bit that I couldn't see for myself. At any rate, radiologist overnight didn't think adnexal mass was c/w with ectopic - his words "I've never seen an ectopic that was 11cm". He thought it was a large endometrioma. Regardless of imaging, the ddx was large: ectopic, incomplete SAB, torsion, appy, hemorrhagic cyst. She had *complete* resolution of her pain after D&C and we told ED that CT didn't seem necessary. I signed off at that point. If CT findings contradicted our diagnosis, we should have been re-consulted.

-when she re-presented I was in a delivery and the strip was kind of punky. It was one of those nurse holding the phone up to my ear deals and the ED attending said they had patient who had +bHCG with peritoneal signs and tachycardia. I told her that if patient was unstable and they couldn't wait the 30-40 mins for me to finish that she needed to call gyn attending. When I got out of delivery I found the gyn attending who was unconcerned. She said this particular ED attending was jumpy and excitable. I went to see patient (<1 hour prior to shift change) and it was only at this moment that I realized it was the same patient I had seen 4 days before. I thought we should go to OR, gyn attending thought patient was stable and we could await ultrasound and repeat Hct.

I left that morning feeling unsettled about the whole thing but there was no counter-discussion at rounds about the plan. And of course now I'm very unsettled. Mostly at the idea that I didn't advocate more for my plan.

After thinking about this a bit this afternoon I think another learning point for me is not just advocacy but also I'm going to stop being apologetic for being the person who likes to go to the OR. In the last year, I've gotten some flack from attendings about being too eager to take people to the OR. "Of course Jocelyn wants to go to the OR", or "Jocelyn is the sort of resident who likes to do un-indicated surgery". Said jokingly, but only sort of.


And of course I am bothered that there are future colleagues who think I am the sort of careless, thoughtless doctor described below. If you would at all advise a conciliatory email to the involved attendings and the KWC powers that be, I am *always* happy to admit even more fault than I feel I am actually responsible for in order to smooth things over and ensure good future relationships. I'll let you direct me on this point.

Thanks for letting me know. I think I'm going to go drink a green beer now...
-jocelyn
-----Original Message-----
From: Autry, Meg
Sent: Thu 3/17/2011 1:58 PM
To: Chapman, Jocelyn
Subject: FW: Resident Feedback

FYI - I wouldn't comment to them but would be interested to hear your take. Meg

________________________________

From: Nina.Y.Lee@kp.org [mailto:Nina.Y.Lee@kp.org]
Sent: Thursday, March 17, 2011 12:15 PM
To: Autry, Meg
Cc: Steve.Zurnacian@nsmtp.kp.org
Subject: Resident Feedback


Meg -

We would like to give you feedback about a case concerning a delay in diagnosis of an ectopic pregnancy in which a UCSF resident was involved. The resident involved with the case was Jocelyn Chapman. We felt is was important that she receive feedback about this case and she is no longer on service here. The case was reviewed by the DSA WHC peer review committee and scored a P2 (significant deviation from the standard of care) for the 2 attendings involved in the case. We did not score the resident as we feel that our attendings take the responsibility in supervising a resident.

10255074

30 yr old G5P4 with paraguard IUD, who was seen in the ED for RLQ pain, hx of LMP 2 wks prior, and abnormal bleeding. A formal scan showed a large 11.3 x 5.5 x 6.9 cm heterogeneous right adnexal mass with small internal color flow. Bhcg= 2108, hgb=11.3. She was seen, radiology and gyn discussed the images and felt it was not consistent with ectopic. So she had the IUD removed, D&C done, mirena reinserted. The resident and attending felt there was POC on gross inspection. The resident's note indicates that they felt that she did not have an ectopic pregnancy based on the above findings. However, the patient did have some RLQ pain still. They felt her sx were consistent with appendicitis. The ER ordered at CT scan which showed hemoperitoneum and fluid around the liver. The ER attending contacted the resident who said it was still OK for the patient to go home and to follow up in 2 days for another hcg. The gyn attending states that she was unaware of the CT findings prior to discharge. It was felt that at this point the attending should have been notified. If the dx was still ruptured hemorrhagic cyst, likely observation with serial hgb and/or diagnostic laparoscopy should have been done.


The patient returned to the ED a few days later by 911 with acute onset of rlq pain and severe abdominal bloating. Bedside ultrasound showed free intraperitoneal fluid and hb=7.9 hcg=1700. The same resident was on call and was notified of the findings. The formal path was not back yet from the D&C at that time (it was sent routine). The resident discussed the case with the attending (but per the attending they were not aware of the prior CT results) and the plan was made the follow the patient expectantly with a repeat Hgb six hrs later. The patient was signed out to the next team when the repeat hgb came back at 5 and then patient was emergently taken to the OR.

She was found to have 1500cc hemoperitoneum and large right ruptured ectopic and underwent ex lap with right partial salpingectomy and received 2 units of packed RBC transfusion. Post op course unremarkable and she was discharged home on post-op day 3.

Upon review of the second admission, it was felt that the resident did not seriously consider an ectopic pregnancy in a patient with a history of a + pregnancy test with an IUD in, a large mass, blood in the abdomen on mulitple imaging tests and a 3 point drop in hemoglobin. The floating of villi is a test with a margin for error and it did not appear the resident considered that the initial diagnosis of ruptured hemorrhagic cyst and SAB were incorrect. Regardless of the presumed reason for the hemoperitoneum, when the patient represented with anemia and acute pain, it was felt that the patient should have gone to the OR at that time and not had expectant management.

Certainly the staff in this case had significant opporunities for care improvement in this case and have received feedback. However, we did want the resident to receive some feedback about this case too.

Please let me know if you have any questions.

Best,
Nina

Nina Y. Lee, MD
Chief of Women's Health
Walnut Creek Medical Offices
Kaiser Permanente
Walnut Creek, CA

Email: Nina.Y.Lee@kp.org

Sisyphus

Sisyphus - you know, the guy who was punished for tricking the gods was punished by being forced to push a rock up a hill only to have it roll down and have to push it up again. Ad infinitum.

reminds me of a story I heard about the golden gate bridge - I heard they paint it from one end to the other and then turn around and do it all over again. Supposedly takes a year...

The job of doctoring (and probably many jobs but we'll stick with the one I know something about) can feel sisyphean. Behind each patient and each surgery is another one waiting. And even when the day ends, you go back the next day and do it all again.

I often find comfort in the repetition. But even in the moments when you're sure you'll go blind with boredom, something spectacular happens. Sometimes spectacularly bad and sometimes spectacularly good. Either way, it never ceases to put the job in its humbling, awesome place.