Lessons from an Emergency Room Nightmare

By Harold Pollack, The American Prospect. Posted December 18, 2008.

Before the appointment, he had mastered Veronica's hospital record. That already put him miles ahead of most other doctors. It just didn't look right that a healthy gym rat would have a sudden heart attack with no warning and no detectable damage. He had a hunch, which he checked out with five or six senior colleagues. They agreed that a viral infection of the heart, viral myocarditis, was more likely.

He took an EKG, which revealed Veronica's resting pulse of 47. She had previously been so fit that her normal heart rate was already quite low. The beta-blocker Veronica had been prescribed was too potent, and nobody was monitoring it--making her one of many people who become sick from their medication. Mercifully, the internist tapered the beta-blocker. He also arranged for an echocardiogram in order to make a more definitive diagnosis. That echocardiogram is where this article began.

Two days after the echo, we sat in an examining room with a university cardiologist, a wonderfully effervescent, small man with a flowing gray beard and an Irish brogue. My heart initially sank when he said, "I have not read your chart. I want to hear from you." He proceeded to ask Veronica in detail about everything that had happened. Veronica tried to be efficient and precise to fit the confines of our visit. "Slow down," he said. "We have plenty of time. Did the cardiologist say your arteries look 'clean,' or 'squeaky clean'?"

After 15 or 30 minutes of questions, he said, "OK. I am going to stop the conversation now, and I am going to read your records." He methodically reviewed what had been written. "Your internist has written a Bible about you," he happily noted. He went through all the lab values and commented almost flirtatiously: "You have the kidneys of a young girl."

After more back-and-forth, he noted the competing hypotheses. He then looked over the echocardiogram results and said, "This is a classic presentation of viral myocarditis." He noted that a damaging heart attack would have shown a dead or damaged region, too weakened to support the heart's syncopated beat. I cannot imagine what cardiac patients experience when they watch live movies of their own hearts in visibly damaged condition.

My own heart skipped when he said to Veronica: "Your echo clearly shows a heart pumping poorly from the myocarditis." It wasn't just the beta-blockers that were making her winded. Her right atrium was enlarged.

As this article goes to print, Veronica is doing well but is facing a nine-month recovery. We have one loose end. Veronica's university-hospital record says that she is on aspirin and a blood thinner and that she is recovering from viral myocarditis. Yet if she falls ill tonight, an ambulance will deliver her to that community hospital, whose records indicate that she is a recovering heart-attack patient taking a potent dose of beta-blockers. Nothing in our health-care system reliably reconciles these different versions of reality. Everyone involved seems skittish to close this loop. What will we tell her original cardiologist? Will he worry that we will sue? Will he argue with us or with the other guy?

People draw their own lessons from intense experiences. Perhaps most frightening is the ease with which smart people make bad mistakes and never look back. Cognitive psychologists have documented the impact of imperfect heuristics and biases on medical decisions. It is hard to overstate the power of getting stuck in a groove, particularly when psychological crosswinds or workplace pressures distort our thinking. A wealth of data confirms this observation when we are driving a car, buying a home, or diagnosing a seriously ill patient. Such findings provide a human frame through which to view many mistakes in Veronica's care, including mine.

Our community hospital did a great job that first day. The cardiologist performed an expert angiogram. We are grateful, even knowing that they overlooked the myocarditis when Veronica's presentation cried out for this diagnosis. She had recently experienced a bad viral infection. She had no sign of artery or heart tissue damage consistent with a heart attack. Every doctor I know has said: Yup, of course, viral infection.

Medical errors seem more egregious in hindsight than they actually are. Groopman's How Doctors Think recounts many serious mistakes but also several heroic diagnoses made when doctors spot things others have missed. But many of these cases just don't seem that hard: the chronic anorexia that turns out to be celiac disease, the ER patient with chest pain who turns out to have unstable angina, the overlooked infected abscess. These examples are frightening because they reveal how skilled professionals go astray.

I can't say why Veronica's doctors missed her heart infection, but I have some clues. For one thing, Veronica's doctors never performed an echocardiogram. Such missed opportunities are common. Tejal Gandhi of Brigham and Women's Hospital and colleagues recently examined closed malpractice cases involving missed or delayed diagnoses. More than half included some failure to order an appropriate diagnostic test. This pattern may be hard to generalize. Only a tiny proportion of medical mistakes and injuries result in malpractice claims. Moreover, a missed diagnostic test is an especially provable form of malpractice.

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Harold Pollack is an associate professor at the School of Social Service Administration, and faculty chair of the Center for Health Administration Studies at the University of Chicago.

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