Damned If You Do/Damned If You Don’t: Why ER Doctors Can’t Win

I just read a story in the news titled something like: “She was discharged from the ER twice, then she died.” It was a link I couldn’t help clicking and after reading the story I arrived at a familiar conclusion: It is hard to be an ER doctor.

The down and dirty of the story is there was a healthy girl in her 20s who developed a cough and difficulty breathing. She went to the ER twice, was discharged with a breathing treatment and a diagnosis of a viral infection. Then she died of an undiagnosed pulmonary embolism (blood clot in her lung). Her parents are understandably distraught and suing the hospital and the doctor for their daughter’s death. I can understand their feelings. Their daughter was right there. She was right were she needed to be in the presence of the tools that could have saved her – but they sent her home.

I’ve heard that basic sentiment in other articles like this. Why, why didn’t they order the test? The test would have saved them! Why didn’t they order it??

Well I’ll tell you why. Because despite all the incredible advances in medical knowledge, medicine is obstinately murky. Over testing is a big deal and it’s consequences are outrageous medical costs, increased cancer risks, over treatment, increases in pain and suffering, to name a few. So doctors have to weigh risk vs benefit. They have to sift through hundreds of patients with similar complaints and try and decide when certain tests are really indicated. But they can’t get it right every time. It’s not a question of if they’ll miss something – it’s a question of when, and you can bet your bottom dollar that keeps them up at night.

The girl in question didn’t die because the doctor screwed up. She died because she was statistically unlikely to have a PE. She had the risk factors of being on birth control and having a mildly elevated heart rate. But do you know who else is on birth control and has a mildly elevated heart rate? Almost every other 20 something female who comes to the ER for a cough and trouble breathing. And do you know what almost all of them have? Something minor like a viral infection. If that doctor ran a CT for every patient that presented like that he would be practicing irresponsible medicine.

Not long ago I had a patient whose family was absolutely livid about the tests we were running. His vital signs and white blood cell count qualified him for what we call a ‘septic work up’ which involves several extra blood draws. They had been through this before. “They never come back positive! They do all these tests and put him through all this extra pain and they are always normal!” Why all the testing? Why? They had a little baby cousin who had just had a septic work up, and guess what? Everything was normal! I asked them what they would think if their little baby cousin had been very sick but the doctor had missed it because they didn’t do the work up. Wouldn’t they be asking the opposite question?

Damned if you do. Damned if you don’t. A doctor I worked with caught a very subtle case of sepsis in an infant years ago. When I asked him how he knew to do the tests he just shrugged and admitted he almost missed it. “But for the grace of God, there go I”, he said. And so every time I walk into my ER I pray for that grace over our doctors – that while trying to make those tricky, murky calls they won’t miss anything that will come back to haunt them.