Of course, everyone makes mistakes, but it’s a bit more alarming when a doctor makes one. Sometimes, life-threatening. These doctors share the worst thing they’ve seen for a patient that another doctor overlooked. Content has been edited for clarity purposes.
A Mix Up At The Pharmacy
“I was verifying a refill prescription (second fill of the medication) for a patient when I realized that a different pharmacist who had verified it a month ago had mistakenly allowed pantoprazole to be dispensed instead of paroxetine.
It wasn’t fun explaining to the patient that instead of getting an antidepressant for the last month, he had been given medication for acid reflux. It had been a new medication for him so he didn’t know the name and didn’t question it.”
“A couple of years ago while I was on overnight call at a Veterans Affairs hospital (VA), I had a relatively routine call asking to transfer a patient to our psychiatric unit from a community hospital’s emergency department for the treatment of psychosis. He was an older guy (I want to say in his early 70s), who came in acting strange and delusional. His son-in-law told the emergency department staff that he had received care with use for psychiatric issues before. I asked them to fax me the transfer packet and the bundle of assessments they already performed there for the patient and in the meantime, I would start looking at his chart.
However, what I found was that he had not been admitted to our psychiatric unit. Instead, he had been seen by our psychiatry consults team for delirium while he was admitted to the medical floor for decompensated heart failure. For anyone unfamiliar, delirium can occur with any severe illness where your brain isn’t functioning properly due to the physiological stress your body is under. Sometimes it just manifests as confusion or disorientation, but sometimes it can get more dramatic, with delusions and hallucinations.
From what I saw in his chart, he had no actual primary psychiatric issues and had only been seen by the consulting psychiatrist while he was delirious.
So when I received the transfer packet for this patient, I noticed there weren’t any cardiac workups for this guy who has a known history of heart failure, but there also weren’t even vital signs on him. The only labs were a blood count (pretty unremarkable), and electrolytes/kidney markers. These chemistries were also not too abnormal, but I noticed that his urea nitrogen was a little elevated. This was generally a sign of poor perfusion through the kidneys, as reabsorbing this urea also helped the kidneys reabsorb every last bit of water they could when the body is dehydrated. However, dehydration and low blood volume were only one possible reason why the kidneys might see reduced perfusion; another possible reason would if some had uncontrolled heart failure.
So I called the outside emergency room and told them that I would not accept this patient onto our psychiatric floor without at least a basic cardiac workup. I told them his history in which he had only had psychiatric symptoms in the context of delirium from heart failure, and the little of data they sent me pointed to that again recurring.
They told me okay and that they would get the labs and vitals done. Once completed, they would reach back out to me.
I didn’t hear back from them after this, and I assumed they had found evidence of cardiovascular decompensation and had reached out to the medicine floor to transfer him there instead.
So I went about my night, and a couple of hours later I got a call to come to evaluate someone in the emergency department I went down there, and while I was using one of their computers I overheard one of the emergency department doctors mention something about a patient coming into medicine from the same hospital. I was curious, so I asked if it was a guy coming in with decompensated heart failure. I was informed that not only was it the same guy–who would have probably been getting a psych consult for delirium at that time–but that he had actively been having a heart attack in their emergency department.
Needless to say, I was pretty upset that this outside emergency department tried to send this guy to our psych unit, where it was a lot harder to get other medical treatments, without even getting vital signs on him or realizing that he was having a heart attack.”
A Broken Arm
“On my surgery rotation, we had a case where a kid broke his arm and went to the Orthopedist (Ortho) who splinted it and put him in a cast. During the follow-up appointment, he complained of a lack of sensation in his fingers but could still move them. Ortho doctor said it couldn’t be compartment syndrome because that would be incredibly painful and not just a lack of sensation.
Spoiler alert: it was compartment syndrome and the loss of sensation was because his nerve fibers had already died. The theory was that he didn’t really notice the pain because of the pain meds he got for the fracture in the first place.
So soon after, he didn’t have any movement in his fingers anymore. So our case was joint Ortho and plastics trying to go in and salvage as much of the arm as possible after getting the cast-off and seeing the damage. Everything on the inside was necrotic, but the kid really didn’t want the amputation, so they ended up cleaning out the forearm so it was just radius and ulna plus the blood vessels to the hand, no muscle or nerve left to salvage. This way the kid could keep his 100 percent useless hand if he wanted.
It was a super tragic call, last I checked the family was suing the original Ortho doctor.”
She Was In “A Life-Threatening State”
“A few years back, at the beginning of my career, I wanted to make some extra money and worked a few days a month in a small town in after-hours medical care. It was not an ER, more like General practitioners’ grade cases during nights/weekends.
I had this mother come to me with her three-year-old daughter, telling me the kid had a urinary tract infection, but the antibiotics prescribed by her General practitioner (GP) weren’t working. Her main symptoms were polyuria (peeing a lot) AND polydipsia (drinking a lot). The three-year-old girl had been drinking four to six liters of water a day. She showed me the urine test she had with her (on basis of which she was administered the antibiotics) and the glucose level was elevated. I don’t remember the exact value, but the previous doctor overlooked this.
We took her blood, checked her glucose level and it was around 800 mg/dL (milligrams per deciliter). It was VERY high, which might lead to ketoacidosis, which is a life-threatening state.
I called the nearest children’s hospital, arranged her admission to an endocrinology department, called an ambulance, and had her transported there in less than an hour. The girl had type one diabetes. I met them once more a few months later when the girl came to me with some kind of flu. The mother started crying when she saw me and thanked me for saving her baby.
This might not sound spectacular, but during the following few years of the job, I treated or took part in treating hundreds or even thousands of patients. I performed resuscitations (some with success, some not so much), had patients with strokes, and still, this is one of the patients I remember the best, and I feel most proud of.”
Was She Really Having A Break-Down?
“In my psychiatry residency, I was working in the psych emergency room (ER), and one night we got a transfer from the main emergency room. Her family had brought her in for ‘Altered Mental Status’ that had been getting gradually worse over the past two weeks. She had been ‘cleared’ by the emergency room doctors (all labs and vitals had been normal) and I was told she was likely having a mental break-down or psychotic episode.
She was rolled into our area and I went to assess her. She was non-responsive, staring off into space, crying and shaking her head back and forth and mumbling. She could not answer any questions and seemed to be having a tremendous amount of anxiety. As a psychiatrist, one of the biggest lessons my mentors taught us was to assume a change in mental status is always a medical condition until proven otherwise and then you can think about psychiatric causes.
Within a couple of seconds of me seeing her, I had a gut feeling this was not psychiatric. I looked through her chart and saw she had a history of blood clots in the past. Her vitals were rechecked and again they were normal. At that point, I made an executive decision and ordered a stat Computed Tomography Scan of her chest looking for a possible clot. The technicians who came to take her for the study were slightly confused as to why a psych resident was ordering this, and the radiology team even called me and wanted to make sure I had not ordered it by mistake.
Thirty minutes later I got a call from the on-call radiology resident and she said, ‘Are you the psych resident that ordered this Computed Tomography Scan?’
I said, ‘Yep, that’s me.’
Thinking I was about to get some comment about wasting their time.
She continued, ‘And this patient is in the psych emergency room?’
I answered, ‘Yes.’
She said, ‘Well, you better call the emergency room and have her transferred stat because this lady has the most massive pulmonary embolism I have ever seen and will likely code any second.’
So with that, we transferred her back to the emergency room, she was admitted to the hospital and treated for her clot. Within a few days, she was back to normal.”
A Snake Bite
“A two-year-old patient and the dad were out in the fields near a small town that was several hours away from the nearest big city, where I worked.
The dad took the child to the emergency room in the small town with an obvious snake bite, the doctor there said, ‘Eh. It’s ok, she probably didn’t get envenomated.’
The doctor didn’t even give the patient antivenin, which they had at that hospital. Instead of electing to send the child to us by helicopter, he sent the child by ambulance.
Several hours later, the patient finally arrived at our hospital, but was coding and ended up dying.
I thought why didn’t the doctor think the patient got envenomated?! That was a dumb idea. If a tiny child gets bitten by a rattlesnake, you assume they’ve been envenomated and you treat them as though that had been.”
A Cardiac Stress Test
“I once had a new admission come to me overnight in the hospital who was admitted by someone else the evening before. The patient very clearly had an out-of-hospital cardiac arrest at a local casino with a defibrillator used with the return of spontaneous circulation. The history was clearly described by the admitting doctor however they called it ‘syncope’ or passing out. They had ordered a cardiac stress test for the morning. That’s when I caught it early that morning.
Ended up needing to go emergently to the cardiac catheterization lab and getting stent to the heart artery which was the cause of their hearty stopping. If the admitting doctor had actually obtained a stress test on this patient, it would’ve killed them.
I have literally tens of stories like this. It feels like half the doctors I work with are morons and literally doesn’t care. But I do want to clarify something and also defend doctors. Medicine is super hard. Period. It’s one of those things where the more you learn, the more you basically realize there is to learn and you always have a state of never feeling like you know enough. Also, there are limitations in modern medicine and we frankly don’t know sometimes. Also, most people are truly trying their best so I don’t wanna talk badly about all doctors. The system we have in the United States as many are aware of knows it’s terrible. This also is on our side as well as practitioners.”
“He Got A Variety Of Dianoses, But Never Treated”
“After we got married we struggled a lot and nearly divorced because he would go through phases where he behaved like a different person. I had kind of noticed it before marriage, but then I stopped working and it became clear that he was struggling with something. He had had a lot of problems his whole life starting with getting a felony when he was still in middle school. By his early 20’s he was in prison because he was doing dope, burglarizing homes, drinking and driving like a maniac, etc. He got a variety of diagnoses like Narcissistic Personality Disorder and Sociopathy but never was treated or medicated. One doctor told him he was untreatable. Despite all of this, my husband got out of prison, stayed sober for years, got a bachelor’s degree and graduated with honors, moved to a new city but then started struggling again with a drinking problem before I met him. We partied a lot at the beginning of our relationship.
Fast forward to a few years later when we were married and mostly sober and living in a new city, but my husband was periodically acting crazy and then went back to normal after about two weeks. I started charting his behavior and statements he made because he would say things like, ‘I never need more than a few hours of sleep, babe!’ Then, two weeks later, he would say, ‘I always have a hard time getting up in the morning, babe!’ I had my Diagnostic and Statistical Manual of Mental Disorders from when I was a psychology major in college, and I started comparing his symptoms to bipolar disorder. He met all of the qualifications. I was able to convince him to start therapy and bingo! He got a bipolar diagnosis within a few sessions, especially after reviewing his history. Even so, everyone was reluctant to prescribe him medication. A full year went by and he was still really struggling. Then he went into a full-blown manic episode and started saying things like that he felt like he couldn’t control himself, so I took him to the emergency room
In the emergency room, I told the doctor I wasn’t leaving until he got medication because he was clearly suffering and needed help now. The doctor not only 100 percent agreed, but she also called his therapist and lectured her for not trying harder to get him medication. He got a hefty dose of Seroquel. We went home and he slept for two days.
He woke up like his normal self again. It took another two years of trial-and-error before his medication was balanced out, but the difference was amazing. A huge list of problems such as rapid heart rate, insomnia, difficulty keeping on enough weight, and nausea every morning, etc just disappeared once he was medicated for his mental health issues. Even his drinking problem just vanished, no joke. He struggles to finish an adult beverage and rarely even opens one.
Now he is as normal as someone without mental health issues and often wonders what his life would have been like if he had gotten proper help at so many different points in his life. He never stood a chance without medication. And then, even when we knew what was wrong, what would that year of our life (when we nearly divorced and my mental health spiraled out of control) have been like if he had gotten medication right away? I know mental health can be tricky, but his problems were brushed aside over and over again by numerous mental health professionals. Ugh.”
A Thousand Dollars Wasted On An Ultrasound
“My dad is an ultrasound and CT (Computed Tomography) tech at a medical university hospital.
He once told me about a middle-aged woman who was complaining of abdominal pain. The doctor (probably a resident, but that’s no excuse for what she or he did) went down their mental checklist of ‘woman with abdominal pain’ and ordered a transvaginal ultrasound to check for uterine cysts. Except that no one bothered either to take the patient’s medical history or look at it.
So in the middle of this ultrasound, my dad discovered that it couldn’t be uterine cysts because she has no uterus. She’d had a hysterectomy several years back. A thousand dollars spent on an ultrasound that provided absolutely no useful information because the moron in the white coat didn’t stop to think. This is a reason American medical care is so darn expensive; you get the tests because a checklist says so, not because someone thought about what information the test would actually provide and what could be done with that information.
Dad was a nuclear engineering tech in the Navy before he went into medicine. When you work on a nuclear reactor, every task has been tested to determine the optimal procedure, and everyone is required to follow that procedure. There’s no ‘Well, this is the way we do it here’ tribal knowledge. My dad gets so incredibly frustrated that medicine is the complete opposite of that. Every doctor does his procedures differently, because he’s still doing them the way he learned to do them in his residency 5, 10, 30 years ago. What method actually works best to do each routine task? No one knows. So he’s stuck doing tests that doctors order without knowing what they do, what they’ll do with the information, or with any notion of why you get this test for that problem if X is your doctor and that test for the same problem if Y is your doctor.”
Six Months Of Complaining
“I was working nights and a patient came in for a nailbed repair under general anesthesia. It was a slow night. So as they were anesthetizing him, he aspirated. We did a chest X-ray to see if he had any spit or blood in his lungs.
What we didn’t know was that prior to this emergency surgery, he’d been going to his GP (general practitioner) for over six months complaining about chest tightness. They’d put him on various different asthma medications, but none had any effect on him.
The X-ray showed a massive dark mass in his left lung. We kept him asleep and transferred him to ICU (intensive care unit).
His wife and three-year-old daughter were waiting for him on the ward. We had to tell them where he’d gone, why he’d gone there, and what was going to happen. He died from lung cancer within the month.
A general anesthetic is absolutely ridiculous for a nailbed repair but he refused to have it done under local.
The dark space in his lungs was the normal lung, and the rest was whited out because they were riddled with tumors. This man was in his late 20s, a non-smoker, and I couldn’t move past the situation for months after it.”
He Took Another Look At The X-ray
“While I was doing a Trauma and Orthopaedics rotation in a small hospital with a decidedly ropey Accident and Emergency department (A&E). I was asked by the medical team to review a 67-year-old lady who had fallen at home. She had some shoulder pain, A&E had X-rayed and ruled out broken collar bone and shoulder and referred to medics to investigate cause of fall.
She still had pain and the medics didn’t completely trust ED (emergency department) so asked me, the chubby but mostly competent Trauma and Orthopaedics senior house officer, to have a look.
Looked at the X-ray first, nothing was broken, then I saw the patient. Her shoulder was a bit bruised but good range of movement. I felt the shoulder a bit more, felt some weird lumpiness (like bubble wrap) under the skin, and thought, ‘Oh no, this is surgical emphysema.’
Surgical emphysema is basically air where it shouldn’t be, in this case in the skin and subcutaneous tissue from the hole in her lung.
I went back to the shoulder X-ray, looked at the snippet of the lung in the X-ray, and saw a big pneumothorax (punctured lung) and a hint of some broken ribs.
We did an emergency chest drain and transferred her to the trauma center. The patient survived.
I don’t think the ED doctors had even laid hands on the patient. Just looked at the X-rays and referred on.”
Sudden Hearing Loss
“A patient came to the Otorhinolaryngology Out-Patient Department with complaints of sudden hearing loss. He had visited his physician the previous night who did a routine examination of the Tympanic Membrane to check for perforations and brushed it off saying it was nothing severe and gave him some anti-histamines for his cold as he suspected a block in the Eustachian Tube to be the cause.
The next morning, he noticed his hearing loss has not reduced and had actually worsened. So he came to us with this same complaint but only except we noticed that the patient was afraid of walking without support as he had imbalance and Vertigo. We quickly did tuning fork tests and found that he had sensorineural hearing loss and suspected inner ear diseases. We ordered a CT scan in which we diagnosed Vestibular Schwannoma ( Acoustic Neuroma) which had invaded the CP angle.
It was a benign tumor of the Inner Ear and we promptly referred the patient to a Government-funded hospital for further treatment according to the patient’s wish as he didn’t have enough money to undergo surgery in our privately run hospital.”