Thursday, 4 October 2007

Does a wrong cancel out a right?

This week I did what every doctor hates doing. I missed a diagnosis. I don't mean I missed an ear infection. I mean I missed seriously ill kiddy with a serious heart condition.

I was on-call for neonatology this week, and was called to labour ward for a delivery. They called me because they were using instruments to deliver the kiddy. When I arrived, the obstetrician was there, trying to haul this baby out of mum with a suction device. But the little one wasn't for coming. It took an age for him to come out. It was pretty horrific to watch. But i had the luxury of being able to stare at my feet, while mum was crying out for morphine.

Anyway, the baby eventually decided to pop out. Delivery had been long and difficult. Morphine had been given, which often has the effect of producing a sleepy baby at delivery.

This baby was indeed sleepy. His colour wasn't great either. But he was breathing, and had a good heartbeat. I needed to give him a bit of oxygen to pink him up, which worked a treat. Dad asked me why I needed to give his newborn oxygen. I replied cheerfully that the kiddy was just a bit stunned by the rough delivery, and the morphine had muted his natural responses. No probs, I'll have him right as rain in no time. And I did. I gave him back to his proud parents about 5 minutes after all the drama. Happy days.

Until the following morning, that is. One of my colleagues was on-call the next day. He was called to the post natal ward to see a newborn that the midwives were a bit concerned about. They had every right to be concerned. the baby was blue. Not a nice sight to be greeted with first thing in the morning.

So, everything kicks into action at this point. There's drips, there's lots of drugs, there's heart scans. Cardiologists turn up, and ventilator machines are rolled in. The parents were inconsolable.

It was the baby who's delivery I'd been at. I cowered in the corner. I couldn't look mum or dad in the eye. It was, shamefully, a relief to me when they were on their way to the local kiddies cardiac unit to be assessed for surgery. I don't know if I should have picked up the diagnosis at the delivery. I still don't know what the diagnosis is. I don't think there were any hard signs or symptoms at delivery. But would somebody else have acted differently? Would somebody else have referred this baby to the cardiologists earlier. Who knows? What i do know is that I didn't.

Later, in the same on-call shift, I was called to A+E to see a small baby. The GP thought he had reflux, and the A+E doc agreed. But he wanted me to see the kid "because mum is anxious and I'd like you to reassure her". I agreed. I always agree. I shouldn't, but I do.

The child had been vomiting for the last few weeks. He was now vomiting everything that he was taking in. He didn't look well. I made him nil by mouth, put in a drip and took some bloods. I suspected a condition called pyloric stenosis. I suspected he was in the very early stages. Pyloric stenosis is a condition where the muscles in the gut become so thick that food or liquid can't pass by them. It's a very serious condition, but with surgery, the outcome is very good. I did the tests, and my suspicion was right. So, I sent him off to the surgeons for his operation. Que 2 very grateful parents.

So, there we go. In one long long day I see a kid who's parents will forever regard me as the pillock who didn't ever notice their baby had a terrible heart problem, even when she needed oxygen. Then we have the parents who will regard me as the only doctor to take them seriously when their child was ill.

Can I really be both these things? Does my missed diagnosis cancel out my early diagnosis of the pyloric stenosis? Does that make me a doctor of "neutral" abilities?

At the end of the day, it's not about me. It's about getting it right most of the time, and making sure everyone gets a fair crack of the whip. I think we do that most of the time. But when we don't, it's the worst job in the world.


  1. Welcome back!

    I admire your honesty. The way I see it is that you did everything expected of you in the circumstances that presented at time of delivery. The baby obviously deteriorated AFTER you'd handed over care to the post-natal staff and therefore the responsibility of care was surely in their hands, not yours.

    Perhaps you could have done more, who knows? But at least you'll have gained valuable insights from this experience and that has to be positive for your future patients.

    Congrats btw on your subsequent early diagnosis.

    Regards, Steph

  2. Missed you!
    I also appreciate your honesty!

    Reading your scenario, there was no mention of fetal distress prior to the birth, although one would presume that some distress would occur. I feel you did everything possible at the time of delivery. I agree with Steph regarding post-natal deterioration where the responsibility had been passed on.
    Don't be so hard on yourself!

  3. EashtGalwayWoman23 October 2007 at 15:06

    Fetal distress wouldn't be present in for example a TGA baby, and if they have an intact septum they go blue pretty quick, BUT if not it's easy to miss.
    As a heart mom we lobby for a quick pulse-ox on all newborns but even that would miss some of the heart defects.
    If it makes you feel any better my friend's kid had HLHS and it wasn't picked up on for 18 hours. How the hell do you miss that? It wasn't until her ped. visited and checked her femoral pulses that they twigged something.
    Good call on the second kid. My TGA (smurf-blue in 15 seconds after birth) had GERD and it's easy to miss pyloric stenosis in the beginning. You saved that family and child a lot of agony.

    How is pediatric cardiac surgery in Ireland? Is it available in all the provinces or just Dublin?

  4. If memory serves me correctly, several congenital cyanotic heart conditions wouldn't necessarily present for 24 hours or so after birth anyway (until the ductus arteriosus closes). I wouldn't be too hard on yourself!

  5. Oye! I may be a patient but I'm not THAT PATIENT! When are you coming back to tell us more about life in NZ? You're sorely missed Dr Thunder.

    I hope life is good but it's can't be THAT good, can it? Bloody hell!

    Come back soon,