Future Leaders Communiqué Volume 4 Issue 3 July 2019
Download PDF: FL Communiqué July 2019
Case - A Missed Diagnosis
Meningitis - Demystifying this enigma
Restraint - A Fine Line
Comments From Our Peers
In this issue, we review a coronial inquest into the death of a young woman who was misdiagnosed. The medical practitioner looking after this patient was a junior doctor working in a busy emergency department. More often than not, when we take shortcuts our diagnoses are usually correct and minimises delay and optimises the use of resources. Like any double-edged sword, shortcuts also increase our vulnerability to making to diagnostic errors, which in this case, resulted in a catastrophic outcome.
Diagnostic errors are challenging to eliminate, especially when there are other contributing factors including fatigue, distractions while multi-tasking and being time poor or under pressure from a large workload. It is easy to look at the case of Ms M’s and identify the mistakes made, thinking that we would not have made them in the same situation. As the saying goes, “Hindsight is 20/20”. Like this junior doctor, and every other doctor in clinical practice, I too have made diagnostic errors.
I remember Mr C, who I met during my clinical rotation in General Medicine in a small rural hospital. Mr C was an elderly man who presented to the Emergency Department complaining of being lightheaded. His oral intake for the previous few days had been poor. A diagnosis of postural hypotension due to
hypovolaemia secondary to a poor oral intake was made. Treatment with one litre of intravenous fluids had a good effect. Once Mr C’s blood pressure improved, he was discharged home by the junior medical resident who advised him to keep up his fluid intake.
When Mr C re-presented with the same symptoms late in the evening I was asked to assess him for an inpatient admission. I was the first one to complete a medical assessment as there was only one emergency department resident who was preoccupied with another patient. Blood tests were not performed as pathology services were limited at this time in the rural hospital. Given that Mr C had previously been seen by an experienced and reliable emergency department resident, I trusted the initial diagnosis made that morning. The information Mr C gave me also supported this. As I was tired and hungry, I did not consider other alternative diagnoses. However, Mr C appeared fatigued and the fact that he had re-presented with low blood pressure niggled at me. I decided to take a tube of blood for a venous blood gas. I was shocked to find that the test results revealed a haemoglobin level of 60g/L!
Subsequently, pathological services were called in to run formal blood tests and facilitate a blood transfusion for Mr C. He remained stable overnight and had an endoscopy the next day that revealed a bleeding peptic ulcer. It was endoscopically treated and he was discharged from hospital a few days later. The case of Ms M’s we present in this Future Leaders Communiqué issue reminds me how easily my misdiagnosis that could have resulted in an unfortunate outcome.