No one is perfect, that even applies to medical professionals. Even with years and years of experience and education, doctors can sometimes make mistakes. These doctors share the time they witnessed one of those mistakes with a patient that another doctor overlooked. The end results were life-changing.
Content has been edited for clarity
“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.”
“When in training I saw a child suspected of having meningitis. While I was new to pediatric medicine, I had a gut feeling just by looking at the four-year-old patient that he was too sick just to be a regular child sickness. The thing that tipped me off was the child was having a slight delay in the pupillary reflexes.
After seeing the child, I asked the head pediatrician to do a lumbar puncture to investigate the spinal fluid for signs of infection. She said there was no need and all signs pointed to some airborne sickness that was roaming around that time. An unnecessary lumbar puncture can scar children for life and whatnot.
While I didn’t agree, I mistakenly doubted my assessment and assumed the doctor with tens of thousands of hours of experience would surely know better than me. I shrugged and wrote everything down in the dossier and asked the pediatrician to read my evaluation afterward. I went home after an exhausting evening, having worked almost fourteen hours straight.
Three days later the child came back with fulminant meningitis that had taken a bad turn. When discussing the patient, the head pediatrician remarked she noticed bizarre pupillary reflexes in the patient.
Not only did she discount my suggestion of doing a diagnostic lumbar puncture, but she also did not read my evaluation of the patient three days earlier. I learned to never doubt my gut feeling and it has led me to some outlandish diagnoses sometimes.”
“His Concerns Were Dismissed”
“A guy came into our ICU and was very septic but still talking. He had visited his primary care MD with complaints of a sore throat for a couple of days. His concerns were dismissed without any intervention since he didn’t appear to have strep throat or the flu.
At this point he was having pretty severe abdominal discomfort, so we sent him for a CT scan. As the scan was finishing, he coded and had to be intubated, multi-organ failure, etc. The CT scan was horrible – he had all kinds of stuff happening all over his peritoneal cavity.
His wife told us that he had choked on an ice cube the day before he saw his primary care MD. He swallowed a whole double half-moon-shaped ice cube that perforated his esophagus with a huge linear almost a five-inch tear, allowing a significant portion of his swallowed food and drinks to get into his peritoneal cavity instead of his stomach. To make things worse, he had some reflux that allowed stomach acid to get in there as well (likely while he was sleeping).
Once we realized what was going on, he went for extensive washout and exploratory surgeries to repair the damage to his esophagus and other organs. Thankfully, he made a full recovery, but he was very close to not making it.”
Something Seemed Odd
“During my residency, we had this lady in her 60s who was getting progressively more forgetful, just overall declining and getting less and less able to take care of herself. She had been seeing her primary care provider who diagnosed her with dementia. And she saw a neurologist who agreed. She was not able to provide an accurate history.
After talking to her family and friends it became apparent that her symptoms were progressing unusually quickly.
I remembered seeing the point where her new hair growth met her bright red dye and also her nails outgrew her hot pink polish that had me think, ‘Wow, it wasn’t too long ago that she was not only taking care of herself but going to get her hair and nails done.’
The lady in front of me was so far from that.
The neurologist who I was training with recognized this. We had her admitted, and did every test including a lumbar puncture. The workup eventually showed Creutzfeldt-Jakob disease also known as ‘Mad Cow’ disease which there is, unfortunately, no treatment for. She died a few months later but at least we were able to prepare her family that she would only continue to decline so they could make arrangements. Really sad situation.”
They Sent Him To The Wrong Area
“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.”
His Co-Workers Were Worried
“A couple of weeks ago, I was precepting on a step-down unit. We got a transfer from an ER in a different county. The only helpful information the nurse got during the report was that he was found on his floor, after missing work for four days. His co-workers called in for a ‘wellness check’ on him because he lived alone.
They received ‘results’ from his head CT which was just a sheet of paper with ‘nothing remarkable’ written on it and no actual images shown. This man’s rapid test came back as he was getting put in the ambulance for transfer. They also said he was a bit ‘slow.’
This man came to us with no ability to move the left side of his body. He also had slurred speech and had left-sided facial drooping. He couldn’t recall how many days he had been down, answers varied from four to ten days. He got the month and year right but couldn’t tell us if he even had a family. He asked us for water after every single sentence because he was so thirsty. He had failed a bedside swallow miserably. His speech slurring was reportedly way worse from the time he was picked up to the time he got to our floor.
We immediately called the stroke doctor and nurse, who requested the CT results, to see the nonsense we had. After they saw the man again, they requested a repeat CT. This was at a shift change, so after stabilizing him and getting the stroke doctor and nurse there my preceptor and I went home.
I precepted in the ICU the next week. We had two codes back to back, the first was a transfer from another floor (the step-down unit) and one was my patient. I participated in both. Found out hours after the codes that the first code was the patient from the story. He coded and died within an hour of being transferred to the ICU and I never found out if he’d had a stroke or not.”
“One day, we saw a kid in the emergency for difficulty walking. He had been slowly losing the ability to walk over months, and also had random unexplained projectile vomiting episodes. Looking at his records, the kid saw his doctor several times who x-rayed one hip. Then x-rayed the other hip. Then prescribed him medications such as Zofran etc.
It turned out on the exam he was blatantly ataxic (bad coordination) and couldn’t even stand. He failed all our bedside neurological examinations for cerebellum function. At that point in time, I didn’t have as much experience as the patient’s doctor, but it was obvious to me that we needed to do a Computed Tomography (CT) scan on this patient because something was odd.
And I was right, there was a huge tumor in his cerebellum. It was obstructing fluid drainage in his brain too, raising his intracranial pressure and causing vomiting.
I had to call in the neurosurgeons overnight for an emergency drain and he went to the Intensive Care Unit (ICU). Later he had more surgery for the tumor.
My supervisor got pretty emotional about this.”
“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.”
Back To Square One
“I’m a dentist in the United Kingdom (UK). While I was working as a locum in an emergency clinic, I had a man present with a mouth of infections.
He had wanted implants; he went to a private UK dentist who refused to do them due to the patient’s heavy smoking and poor dental hygiene which would mean the chance of success and good healing would be limited.
The patient didn’t accept this, went online, and found he could go to Hungry and get the implants done, for half the price, and have a holiday.
He came back and within a few weeks, most of the implants were infected and there he was, sitting in my chair. We gave him antibiotics to clear up the infection but then we had to inform him that the implants would need to come out and he would need to find a specialist dentist with the necessary equipment to get that done.
He was not happy. Spent all that money only to have to pay again to have them all removed. No better off and at least ten thousand bucks down. This patient should have listened when the first person told him no!”
Uh-Oh Was An Understatement
“I was on call covering via phone for the night for an acute psych unit. The 30-some-year-old female was admitted earlier in the day for psychosis, agitation. She tried beating up a security guard and kept talking about a baby, didn’t look remotely pregnant, right?
Well, I was wrong. The urine pregnancy test was positive. She also had tachycardia and some abdominal pain. So, an obstetrician-gynecologist got involved and ordered an ultrasound.
Ultrasound was completed. It was completed, but no report was written up. Five minutes later, I received a page from the nurses on the unit that the obstetrician-gynecologist consultant was on the floor and was recommending chemical abortion because it was an Ectopic pregnancy. They asked the nurse to relay to me to put the order of Methotrexate in.
I went to look at the Ultrasound report, but still, nothing was in. So I called back telling the nurse that this wasn’t how consults work. The individual consultant should put the order in for any recommendation they were making, as they were on board and following (it’s different at different hospitals. Across the street, it wasn’t like that.)
I also called my on-call attending, apprised them of the situation; the program director, apprised them of the situation; and they had the nurse document the specific language used when the physician was conveying the request that I put in Methotrexate (MTX). I wasn’t going to put in the order, so they all concurred.
With that being said, the obstetrician-gynecologist consultant put the order in.
Hours later, the ultrasound came back and it turned out that the obstetrician-gynecologist consultant had misread things, it wasn’t ectopic at all but a viable pregnancy. Things escalated quickly, and communication went on a total shutdown.
The physician no longer practiced in the same area. I was never informed officially of the results, but a buddy of mine said it was a scorched earth situation that threatened the hospital system altogether. They tried to rescue the pregnancy with some sort of counteracting agent or folate infusion or something, I don’t know.
I checked out and never looked at the chart again because I was scared to death of the situation.”
She Didn’t Even Need It
“It was a twenty-five-year-old patient that this happened to. A doctor put the pacemaker lead in the subclavian artery and across the aortic valve into the left ventricle. The proper approach is in the subclavian vein to the right ventricle.
And then he didn’t notice he put it in wrong for over a year. I saw the patient (who didn’t need the pacemaker in the first place) when she was having congestive heart failure because the pacemaker lead had destroyed the valve!
A surgeon and I had to do surgery to remove the pacemaker and lead. Then we had to replace the aortic valve!
It was totally inexcusable.”
“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.”
If Only She Had Said Something Earlier
“While working as a CNA on an ICU step-down unit, I noticed my patient was acting strange. So, I started asked her a few questions and got some questionable answers. Thought it might be weird, as she couldn’t really answer questions other than ‘huh,’ and ‘uh-huh.’ Her gait was weird (like a trot rather than a normal walk), plus she was leaning.
I was training another CNA and I was like, ‘No matter what you do, if you see something, notify the nurse and chart that you notified her.’
The patient was having a major stroke and the nurse was too far up her own butt and her own phone to do an assessment. The woman had to go to rehab and was not a candidate for any stroke ‘reversing’ drips as I had charted that she seemed ‘off’ eight hours before. The only reason anyone ‘caught it’ was because the night shift nurse insisted on a bedside report.
The nurse I had been working with yelled at me, ‘STROKE??’ like I hadn’t been notifying her of symptoms all day.”