Perspective: Who’s to blame when bad things happen?

This month’s guest “Perspective” is by Mark Plaster, MD, and was first published in Emergency Physicians Monthly, June 14, 2011. It is edited and reprinted with permission. The opinions expressed are those of Dr. Plaster and reflect his experience with a specific case example. Generalization is discouraged./CP

Over the years I’ve gotten many calls like this one. “Will you look at this case? Something very bad happened and I think someone screwed up.” I hate those calls.

The case that comes to mind was both heartbreaking and frightening. A healthy young Asian man, not yet 21, the pride and joy of his family, went to a local hospital ED with abdominal pain. After an evaluation that revealed nothing of substance, the EP decided to admit the patient. While treating his pain, he admitted to the parents that he wasn’t sure what was going on. After 15 hours in the ED complaining of severe, unrelenting pain, he suddenly and inexplicably died.

The young man’s father, a friend of a friend, asked me to investigate. I vacillated between the fear of being unable to give a satisfying response, or worse, having to face and reveal the failure of a colleague.

The father had no records of his son’s previous medical care but said the family history was negative and his son had been relatively healthy and active. He enjoyed breakdancing with his friends.

I looked through the ED record. Severe abdominal pain for an hour or two after a vigorous workout, mostly right lower quadrant, some radiation to the back, no fever, some nausea and dry heaves. It looked much like many kidney stones I had seen. There was a confusing leukocytosis. I could see the EP asking himself whether this might be appendicitis, but a CT of the abdomen didn’t help much.

“So what happened then?” I asked the young man’s father.

“His eyes just rolled back and he fainted. Everyone rushed in and began working on him. They said his heart stopped. They put a needle into his heart, but they didn’t get anything. Then they put a tube into his chest and got a lot of blood.”

But why would this young man have blood in his chest?

I turned to the autopsy results: “Aortic dissection.”

I sat stunned. I had seen pictures of this young man. He didn’t have Marfan’s syndrome. “Friable vascular walls raising the possibility of Ehlers-Danlos Syndrome” commented the pathologist. I questioned the father about elastic tissue. Nothing. I sat quietly processing the awful scene, a whole team of bewildered physicians and nurses trying to resuscitate a young man who had quietly exsanguinated right in from of them.

“There is no possible way they doctors could have known what was happening with your son,” I told the father with finality. “I know that you want to find someone responsible for this awful tragedy. But they did the best anyone – and I mean anyone – could have done under this circumstance.”

“Couldn’t they have done something?” he asked plaintively.

“I am so, so sorry for your loss,” I said, wishing I could reach across the room to comfort the soul of the grieving man. “But the doctors acted reasonably, by anyone’s standard.”

I scanned the chart one last time to see if anything at all would give a clue, some insight into the final outcome. Then I saw it: a clue to the depth of the family’s pain. The record clearly indicated that the patient and his mother had been offered an elective exploratory laparoscopy. There were no details of the discussion, but they clearly had declined the one opportunity to possibly discover the cause of his illness. Yes, the mother was blaming herself for failing her son.

“You need to tell your wife that it was not the doctor’s fault,” I said, “but you need to tell her it wasn’t her fault either. Sometimes bad things happen. And it’s no one’s responsibility.”

Mark Plaster MD

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