Confessions of a GP (19 page)

Mistakes…I’ve made a few

I think medical errors can broadly be divided into four categories:

Type 1. The near miss:
Making a mistake but it doesn’t actually cause any harm to the patient.

Type 2. The cockup but arse covered:
Missing a diagnosis and the patient comes to harm. However, the diagnosis was hard to make and the doctor did all the right things and documented this very well in the notes.

Type 3. The cockup and up shit creek:
Same as the last category, but as well as missing a hard diagnosis and the patient coming to harm, the doctor didn’t document things very well in the notes.

Type 4. The probably in the wrong job:
Making a completely unforgivable mistake that can’t really be excused regardless of the documentation. This might include refusing to examine a patient or repeatedly missing a really obvious diagnosis.

Thankfully, I have never made a mistake in type 4 and hopefully never will. To be fair, I actually think they are incredibly rare.

Unfortunately, I have made mistakes in the first three categories and although nobody really likes talking about their own mistakes, they are probably fairly typical of slip-ups made by young doctors like me so I thought you might find them interesting.

The near miss

As a very junior doctor I was on a ward round with my consultant and a final-year medical student. The consultant said that he wanted a transfusion for Mrs X and asked me to take some blood to send to the lab so that we could confirm which blood group she was.

After the ward round, I asked the medical student how confident he was in taking blood. He was happy to give it a go, so I asked him to go off and take some blood from Mrs X. He came back proudly ten minutes later with the blood and I labelled the forms and samples of blood and sent them to the lab. The next morning as we got to Mrs X on the ward round, she was sitting happily in her bed with her second bag of donated blood running through into her vein. My medical student suddenly turned very pale. ‘Is that Mrs X?’ he trembled. ‘She’s not the lady I took blood from yesterday. I took blood from that lady opposite.’

Now this could have been an absolute disaster. Giving the wrong blood group to a patient can make them very ill and potentially kill them. I had signed the form stating that the blood taken was from Mrs X and therefore would have to take responsibility for the error. The medical student should have checked who he was taking blood from but ultimately, I was responsible for supervising him so again the buck would have to stop with me. Fortunately, Mrs X and the patient from whom my dopey medical student did take blood had the same blood group so no harm was done. I plucked up the courage to tell my consultant what had happened. I was fully expecting the shit to hit the fan, but instead he stuck a fatherly arm round my shoulder and said, ‘Don’t worry, Ben, I made far worse mistakes when I was a junior. You got away with this one, but just make sure you learn from it and don’t let it happen again.’

The cockup but arse covered

I saw a middle-aged man complaining of headaches. His headaches were fairly nondescript with no symptoms of weakness in his limbs or problems with his vision. He hadn’t banged his head and the only thing of note was that he was feeling a bit tired and stressed out at work. I gave him a really thorough examination and documented everything very clearly in the notes, but basically reassured him that there wasn’t likely to be a serious underlying cause of his headaches. A week later he was found collapsed at home and was found to have a brain tumour. His headaches were almost certainly related to this and I had missed it. However, during our consultation, I took him seriously and gave him a really thorough check-over. I also asked him to come back if his headaches weren’t resolving. He is recovering slowly in a specialist neurology hospital after some quite major brain surgery.

The cockup and up shit creek

Some time ago I saw a woman with some odd tightness in her chest. She was well in herself and only in her mid-fifties. She told me that she had the symptoms when she went into town shopping and wondered whether they might be due to anxiety. I asked her lots of questions about the pain to make sure it didn’t sound as if it was because of problems with her heart or lungs. I also gave her a thorough examination, but couldn’t find anything wrong. I had a long chat with her about relaxation techniques and breathing exercises and told her to come back if the pain got worse. Three days later she collapsed with a heart attack. Again I had missed the diagnosis, but sometimes heart problems can present oddly and perhaps many other doctors would have done the same as me. In hindsight perhaps I should have done a heart scan and ordered some blood tests but these might not have made a huge difference. My real error in this case was that my documentation in the notes was really poor. I didn’t write much about the pain she had or the examination I did. Legally, I hadn’t covered myself at all.

As you can see, these three cases are all mistakes of sorts and could have landed me in trouble. As you can also see, the degree of the mistake doesn’t always correlate with the amount of harm that comes to the patient. I have learnt a lot from them and I am a better doctor as a result. The near miss with the blood transfusion was probably the most negligent on my behalf yet as by pure good fortune no one came to any harm, I got away with it completely. Had things turned out differently, I could have been struck off and, much more importantly, the patient could have died.

Missing the brain tumour was the least negligent because I really did do a thorough well-documented history and examination. For the lay person reading this, you may feel that I should have sent the patient to have an urgent brain scan. Unfortunately, I don’t have access to brain scans. My only option would have been to have sent him straight to A&E. As with most GPs, I probably see about 200 people per year complaining of a non-complicated headache. If all GPs sent all of these patients to A&E, the system would collapse. The wife of the headache man is considering suing me. I’m a little anxious about this, but I know that I am completely covered because I’m fairly sure that if 100 GPs read my notes, most of them would have done the same thing as me. I felt dreadful when I found out that I had missed that brain tumour, but without X-ray vision, I don’t think I could have been a better doctor that day.

Mistaking the chest pain for anxiety was similar to the headaches in that it was a difficult diagnosis to spot. However, if the patient had wanted to sue me she could well have been successful. I wrote so little in the notes from that consultation that if she had claimed in court that she had all the classic symptoms of a heart attack or angina, then I had nothing in writing to defend myself. Medico-legally if it isn’t written down, it hasn’t been done. Shortly after the heart attack, the patient came in with her husband to see me. They were angry and upset and wanted to know why I had missed the diagnosis. I made the excuse that it was sometimes difficult to spot heart-related chest pain, but ultimately I held my hands up and said sorry. The hospital cardiologist had fortunately told them that her presentation of heart pain had been very unusual and as he knew me from my days in the hospital, he backed me up by telling them that I was a very good doctor. As far as I know, my apology was enough and they are not planning any legal action.

If I miss a diagnosis, the patient suffers regardless. But from a legal view point, irrespective of how excellent and thorough I was in the consultation, if I’ve not documented my findings, I may as well not have seen the patient at all. I see up to 40 patients per day so can’t remember each consultation. Court cases often come up years after the incident occurs and the medical notes are often the only thing the doctor has to defend their actions. If something goes wrong, the patient will probably think that they have a vivid recollection of the consultation, but often the details of the event can change as the memory is recalled time and time again. An example of this is when a patient says, ‘That Dr X told me I had a year to live’ or ‘The A&E doctor said I would never have children.’ First, doctors rarely commit to these sorts of bold statements and second, when I read the notes from those consultations, the documentation tends to be very different from the patient’s recollection.

It is quite hard for a doctor to admit mistakes and I think what I’m trying to say here is that although I’m not the best doctor in the world, I’m mostly quite a good doctor. Mistakes happen to all of us. I try my best each day to avoid missing any serious health problems but I have made mistakes in the past and undoubtedly will make them in the future. My only other option would be to refer every headache I see for an urgent CT scan and every chest pain to A&E for a hospital admission. Perhaps in an ideal world I would do this but the NHS wouldn’t cope with the strain and it would also cause unnecessary anxiety to many well people.

Some mistakes are genuinely because of negligence by poor doctors. Most mistakes are made by good doctors who perhaps missed a difficult diagnosis or didn’t write enough in the patient’s notes. I hope we don’t become like the USA where ambulances are chased by lawyers hoping to persuade unwell people that it could be their doctor who is to blame for their illness. On the other hand, were it my family member who was ill or dead because of a possible medical error, perhaps I would want some justice too.

Dying

Our frequent close proximity to death and dying is perhaps one of the features that sets doctors apart from people in other professions. For most people, death is fairly sanitised now. It is rarely seen in its gritty reality and many people of my generation will never have seen a corpse or even somebody very ill. The constant exposure to something that most people would find very shocking can’t help but take its toll on your personality and outlook on life. Of course, we don’t suddenly acquire these characteristics upon passing our final medical school exams. Death and dying become gradually normalised as we are processed through the system of medical school and our first hospital jobs as junior doctors. In our very first week at medical school, we were cutting up corpses in the dissecting room. This was partly to learn anatomy, but also an attempt to give us an early exposure to death and help us learn to distance ourselves from it emotionally. I know that I must have normalised dying in my head because, although I have seen hundreds of people die, I can only actually remember one or two of them. Perhaps I’m particularly callous or have an exceptionally bad memory, but as I’m sitting here now racking my brains, I can recall very few of the names or faces of patients whom I have watched breathe their last breath.

Although I now feel very unsentimental towards death, the first patient that I watched die is etched very strongly in my memory. I can picture her face very clearly and I can even remember her name but I’ll call her Mrs W. She was an ordinary 60-year-old woman who had woken up as normal that morning. She had felt fine and had been getting herself ready for what she had expected to be a fairly average day. Somewhere between breakfast and getting ready to pop to the post office, her aorta burst. The aorta is the main artery that runs from the heart, so as you can imagine having it spring a leak is bad news. It was my first hospital attachment as a medical student and I was hanging around A&E trying to learn something and not get in the way. As a third-year medical student, I was in a strange void between being a normal person and being a doctor. I’m fairly sure that no other nurse or doctor who was working that day will have any memory of Mrs W because it would have been just another day at work. But for me, it was all very new and shocking and I still remember the episode in distinct detail. I was seeing death in the way a non-medical person might see it and not from the perspective of the hardened doctor that I am now.

When Mrs W’s aorta ruptured, she had a sudden pain in her abdomen spreading to her back and began to feel faint. She called an ambulance and after the casualty doctor felt her tummy and saw her blood pressure dropping, it became fairly clear that she had burst her aorta (known as a ruptured AAA – abdominal aortic aneurism). She needed an emergency operation and there were all sorts of people flapping around organising scans and getting the operating theatre ready. As a medical student, I had the advantage of not having my own role or job to do. I could just sit with the patient and take it all in.

During the following ten minutes, several more doctors arrived, prodded her tummy and spoke among themselves. Despite being very unwell, Mrs X had been alert and conscious through the whole ordeal. Nobody had really had the chance to tell her what was going on, but from the commotion occurring around her it was obvious that things were serious. She lay in bed connected to drips and monitors, yet stayed calm and immensely dignified. Her husband and daughter were sitting on either side of the bed, each holding one of her hands. The consultant surgeon soon arrived on the scene. He was a big burly man and was already in his surgical blues as he barked instructions at the nurses and junior doctors. I felt a pang of fear just by being in his presence. He marched over to Mrs W, sat down at the side of the bed and took her hand.

‘I’m Mr Johnson and I’m going to be operating on you this morning. You have burst the main blood vessel that runs from your heart. If we don’t fix it, you’ll die. If we do an operation, there is a 50 per cent chance that you will survive.’

The words on paper look unbelievably harsh but Mr Johnson spoke them with an amazing air of calm and gentleness. He refused to be distracted by the surrounding mayhem but instead focused all his attention on Mrs W and her family. Sitting and watching, I was overcome with an amazing sense of how her life lay so tightly in the balance. She could sit up and talk and see and hear, but hidden beneath her skin, she was slowly bleeding into her abdominal cavity and ultimately dying.