“ resulting from the activity of physicians; said of any adverse condition in a patient resulting from treatment by a physician “
Bad outcomes occur in medicine hundreds, if not thousands, of times everyday. Medicine, for all of it’s advances, can only go so far. Diseases take their toll on the body past the point of recovery and even the most skilled physicians can’t always save the victims of trauma. This is understood and accepted by the medical community, that the reach of medicine only extends so far. But what happens when it is medicine, not disease, that results in the death of a patient? Worse, what if the death resulted from a perceived lapse in judgement?
I’m not a physician and with that I know that there are so many complex things about the body that I haven’t the slightest idea about. However, that doesn’t mean that I don’t have the competency to question a decision that might cost a patient their life.
A few days ago we had a patient who presented to the ER with complaints of right leg weakness and difficulty speaking. According to the patient and family, the symptoms started about 45 minutes previous while at a store. The difficulty speaking had seemed to have, at least for the moment, resolved itself while the weakness in their right leg continued. After obtaining a history, we learned that the patient had had multiple orthopedic surgeries on their right leg in the past year which had resulted in numerous complications including nerve and muscle damage, which probably contributed to the right leg weakness. The weakness, per the patient, had been a chronic problem that they felt got worse today (talk about a difficult historian) but regardless, they were still having this seemingly transient problem with their speech. While we were in the room even, the patient suddenly had difficulty forming words, even though they could clearly understand what they were saying. The episode only lasted two minutes and suddenly resolved.
To the physician, the nurse, and myself, it seemed that the patient was having TIAs (Transient Ischemic Attacks also known as “mini strokes”). After a completely negative stroke workup, including a normal CT scan of the head, the on call neurologist was called to come consult on the admission. After hearing about the patient on the phone, for some strange reason, the neurologist decided they wanted to administer tPA ( a very powerful fibrinolytic used in this case for ischemic strokes). This seemed troubling to us, seeing as how tPA is strongly contraindicated in TIAs because of the occurrence of hemorrhagic events in the brain. So, the ER physician asked the neurologist to come to the ER and evaluate the patient, and if they so wished, to administer the tPA themselves as they were the expert and it wasn’t something the ER physician agreed with.
To make a very long story a little bit shorter, the patient was given tPA directly by the neurologist. An hour later, they developed an intense headache, a nosebleed, and a sharp increase in blood pressure to 190s/100s. The physician ordered a CT scan and we actually went with the patient so we could look at the scans as quickly as possible. It wasn’t good. there were two areas of bleeding on the CT, with one of the bleeds causing a 9mm left-right mass effect. Almost as soon as we found that out, the patient started dropping their oxygen saturation, at which point they were quickly wheeled back to the ER and intubated. We called the neurologist and let her know what had happened and began preparing the patient for transfer because we currently don’t have a neurosurgeon. The patient’s family was distraught and most of them were crying intensely as the flight team took the patient out to the helipad, asking us how this could have happened and why did this medicine cause this. They were upset and confounded as to how 2 hours ago the patient was alive and now they were being kept alive by a ventilator.
The next day, the nurse called the accepting hospital to ask about the patient’s condition. They had died two hours before the nurse called.
There are several patients who I will never forget after I stop working at this hospital, and this patient is certainly at the top of the list. It’s an experience that will always teach me to be 100% confident in the decisions I make regarding patient’s lives, as the wrong decision can unfortunately take life away from them.
I think that what will stick with me the most, however, is that right before the patient got the tPA, they were having a perfectly normal conversation with their family. The very thing that was going to kill them was being administered into their IV, and they didn’t even know it.
I was going through my archives today and saw this post I made about a year ago. Every time I read this I feel like I still have something to learn from the experience.