MISSED CANCER DIAGNOSIS, new grad feeling terrible

[Guest UVAPAC]

For what it's worth, by the time lung cancer shows up on a chest x-ray, highly likely to be stage IV and incurable regardless.  

[Joelseff]

A very good set of friends called me one night as his wife was acting a little forgetful and sleepy.  She was only around 40 and had recently started some new meds.  I told him it was prob the new meds and to keep an eye on her.  A few hours later she crashed. He rushed her to the ER and she was admitted for emergency surgery for bil blocked ureters and subsequent sepsis from a UTI.  They called him to the hospital and basically said she might not make it.  Thank God she did, but it was touch and go for a while.  Honestly, after that our relationship was never quite the same.  There was this underlying tension partially based on my guilt and their resentment.  You like to think that people can get past things like that, but in all honestly most don't.
Fast forward ....we have not spoken to them in about 6 years.

That's why I don't practice curb side medicine...

Sent from my SAMSUNG-SM-G891A using Tapatalk

[sk732]

The words we all dread hearing: "Do you remember Patent X?  Well, they bounced back with (cardiac arrest, saddle PE, some other gooberish horrendoma) and is dead/on life support as an organ donor/just had some goober yanked from their chest/bowel/stomach, etc".

SK

[GetMeOuttaThisMess]

Let’s try one like this:

[Reality Check 2]

Jumped facet at 6. Hopefully breathing spontaneously....

[hlj25950]

I am starting a new job at an urgent care. I’m a new grad. One of the questions I specifically asked in my interview was if they had radiologist overread all of their films. They do. Huge sigh of relief. Radiology is a four year residency. I don’t know about you, but my medical imaging class in PA school definitely didn’t give me the peace of mind to read and interpret my own chest films without backup. Frankly, I think the practice of having a new grad read chest films without an overread is beyond negligent on your SPs part. Most providers I know wouldn’t read their own films unless it’s something they do all day everyday. Orthos get radiology second opinions on MRIs or CTs that are questionable. Unless you’re a pulmonologist or look at chest films for years, there is a huge risk.

Here are the guidelines for lung nodules that are commonly used.

https://radiopaedia.org/articles/fleischner-society-pulmonary-nodule-recommendations

[TWR]

When ever possible NEVER treat family or friends

[Dichotomy]

21 hours ago, Cideous said:

A very good set of friends called me one night as his wife was acting a little forgetful and sleepy.  She was only around 40 and had recently started some new meds.  I told him it was prob the new meds and to keep an eye on her.  A few hours later she crashed. He rushed her to the ER and she was admitted for emergency surgery for bil blocked ureters and subsequent sepsis from a UTI.  They called him to the hospital and basically said she might not make it.  Thank God she did, but it was touch and go for a while.  Honestly, after that our relationship was never quite the same.  There was this underlying tension partially based on my guilt and their resentment.  You like to think that people can get past things like that, but in all honestly most don't.

Fast forward ....we have not spoken to them in about 6 years.

To OP, I sympathize with you as a new grad myself. I can only imagine the feeling but I hope you find some much needed encouragement here. 

Cideous, I am equally sorry for your experience and thankful she is now doing fine. As a new grad, and having already received couple of these calls from friends and families, what would you have done differently? 

Others opinion welcomed.

[surgblumm]

If you don't feel incompetent you will never become a great PA. You are wise enough, to be honest with yourself and colleagues and be truthful about your lack of experience. when I taught on the university level, I always mentioned to my students that passing the NCCPA exam and becoming certified does not make you a PA. A PA or NP or physician is trained in the trenches whereas a physician also has a residency where they are constantly learning through error. Initially, question everything that you are not positive of and ask a colleague of SP as this is how we learn. when I started in an ER while having over twenty years in surgery at that time, I saw that I was deficient in radiological interpretation and requested of the Chief of Radiology that he permit me to sit in the room as he dictated his readings as I learned all of the parameters. Keep your chin up as we have all been there.

[sas5814]

1 hour ago, Dichotomy said:

To OP, I sympathize with you as a new grad myself. I can only imagine the feeling but I hope you find some much needed encouragement here. 

Cideous, I am equally sorry for your experience and thankful she is now doing fine. As a new grad, and having already received couple of these calls from friends and families, what would you have done differently? 

Others opinion welcomed.

I tell everyone who asks that for thier wellness and safety and my liability I can't dispense free medical advice. Sometimes I say "free medical advice is worth every penny you paid for it."

[Cideous]

1 hour ago, Dichotomy said:

To OP, I sympathize with you as a new grad myself. I can only imagine the feeling but I hope you find some much needed encouragement here. 

Cideous, I am equally sorry for your experience and thankful she is now doing fine. As a new grad, and having already received couple of these calls from friends and families, what would you have done differently? 

Others opinion welcomed.

 

See, that's just it.  What could I have done differently?  Not much!  Family and friends routinely cross this line and think nothing of it.  The times I say, "you know I really don't like to give medical advice without a full exam", you would of thought I jumped up on the table and pee'ed on everyone.  The look of "what a jerk!" on their faces is impressive.  So you are left with a dilemma.  Do nothing and be labeled a d*ck, or try and help and roll the liability lottery dice.  It sucks.  Mainly, I avoid friendships with non medical people now and when acquaintances can not be avoided (kids families friends etc), my wife and I absolutely have one rule.  NO ONE knows what I do.  Period.  Honestly, following that rule has been extremely effective.

[thinkertdm]

7 hours ago, Cideous said:

 

See, that's just it.  What could I have done differently?  Not much!  Family and friends routinely cross this line and think nothing of it.  The times I say, "you know I really don't like to give medical advice without a full exam", you would of thought I jumped up on the table and pee'ed on everyone.  The look of "what a jerk!" on their faces is impressive.  So you are left with a dilemma.  Do nothing and be labeled a d*ck, or try and help and roll the liability lottery dice.  It sucks.  Mainly, I avoid friendships with non medical people now and when acquaintances can not be avoided (kids families friends etc), my wife and I absolutely have one rule.  NO ONE knows what I do.  Period.  Honestly, following that rule has been extremely effective.

Send them a bill.  Or show up where they work and walk off with something.  People understand they pay lawyers for expertise and knowledge appllied to their particular situation, but for some reason don't get that 1: they come to us with a problem, which we use brain power to solve- instead, they order zpacks like we are damn ice cream vendors.  2: this interaction takes place in a very controlled environment, where objectivity can be maintained; the human in me doesn't want to think about your discharge when I'm at home any more then you want to think about your cable installing job at home.

I like the bill idea.

[Joelseff]

  See, that's just it.  What could I have done differently?  Not much!  Family and friends routinely cross this line and think nothing of it.  The times I say, "you know I really don't like to give medical advice without a full exam", you would of thought I jumped up on the table and pee'ed on everyone.  The look of "what a jerk!" on their faces is impressive.  So you are left with a dilemma.  Do nothing and be labeled a d*ck, or try and help and roll the liability lottery dice.  It sucks.  Mainly, I avoid friendships with non medical people now and when acquaintances can not be avoided (kids families friends etc), my wife and I absolutely have one rule.  NO ONE knows what I do.  Period.  Honestly, following that rule has been extremely effective. 

 

I ask them "what's your provider say about that?" Or "Have you seen your provider?" and if they force me to "check them out" right there while watching Thanksgiving football and eating gobs of turkey and dressing (usually when it occurs [emoji848]) I do a quick and dirty "exam" or whatever then say "you should have your provider look at that." it likely has led some family to think I don't know much because I am "just" a PA but who cares? I try not to cross that line. I have at times found something troubling... a very close friend asked me about his CKD and that his doctor continues to tell him to "watch it" though it has been getting worse (class 3b now with increasing azotemia) and he is still not on ACEI/ARB. I asked about his BP and it was above 140/90 (not crazy above) I asked him to talk to his doc about lisinopril and see if it is appropriate for him. I don't know his entire hx and would do him and his doc (who is also a friend) an injustice by simply telling him he needs it. He did and now he's on lisinopril... I wasn't his provider just a friend asking and answering questions and I left the actual doctoring to his provider.  Sent from my SAMSUNG-SM-G891A using Tapatalk

 

 

 

 

 

 

 

[lkth487]

I had a family member who always wants me to diagnose their kid over the phone.  But they don't vaccinate at all.  So every time I'm like, "well it could be nothing or he could be dying from a vaccine preventable Illness."   Eventually the dad wisened up and immunized the kid without telling the mom. 

 

Most times, I can just defer the adult questions by lying and saying "I'm not allowed to treat adults".  

[ventana]

On 2/25/2018 at 0:03 AM, GetMeOuttaThisMess said:

Let’s try one like this:

 

 

badness......

 

that is not just a jumped facet - that is ugh bad I think....

[d2305]

Radiologist have read all the films I've ordered. We've all missed subtle finding on CXR.

[mgriffiths]

Disclaimer: I did not read every response above

It is absolutely inappropriate for a radiologist to not be reading imaging.  I used to work in ortho and while we "read" our own imaging, we always had a follow up read from radiology.  You are not a radiologist (and neither is your SP) and have rudimentary training in it at best (unless you did extra training outside of PA school).  Obviously it sucks and you feel bad, but it also wasn't your diagnosis to make either time.  That is a diagnosis for radiology.

At my clinic, I order imaging and will read it myself.  If I believe I see pneumonia, fracture, etc. I treat the problem.  But, a radiologist always reads the images.  I have been wrong a few times, missing a pneumonia where I have to call the patient and start an antibiotic, and I've been wrong starting an antibiotic when it wasn't pneumonia (pretty rare thankfully).  Often I will actually call radiology and request a verbal read so I can make a decision right then.

I'll add my "bad story:" saw an older patient for the first time on a Friday afternoon.  He was complaining of dizziness, but had no syncope, SOB, chest pain, etc.  Still did an ECG because I had a feeling and ordered some labs "stat."  ECG normal.  I never got the lab results back that day and I forgot.  Turns out the patient was significantly anemic (I think hgb around 5-6) and ended up suffering an MI secondary to his anemia over the weekend.  The hospital made a mistake not sending me the lab results, but if I had remembered that I ordered them I would have called and gotten the results and then called the patient directing him to go to the hospital - possibly avoiding his MI.  Thankfully he did ok, and has mostly recovered, but whenever I see him it is a reminder.  The patient is actually healthy enough that will be a reminder for quite some time.

[Acebecker]

I gave a little old lady with a UTI some Keflex and she went into anaphylactic shock, ended in cardiac arrest.  Protracted resuscitation and she was discharged from the hospital neurologically intact.  I have seen her for several UTIs since then and I am still gun shy.  She had had Keflex no fewer than 5 times prior to that day and had never had any sort of reaction.

I've had several other 1/1,000,000 zebra misses.  I hate all of them and I have learned a lot from each one.

 

[BruceBanner]

On 2/25/2018 at 8:04 AM, TWR said:

When ever possible NEVER treat family or friends

Totally agree. Often our friends will call us (they have an infant and a 2 year old) with "what should we do" questions. I dont like being put on the spot with baby problems and usually tell them to be seen. What if the febrile baby turned out to have meningitis or something lethal, and I said "watch and wait", child decompensates rapidly as they can do...forever altered relationship and a life of guilt.

Just reminded me of an Rx I wrote a few months back. Girl had a routine infection, I put her on augmentin. Or thought I did. The patient I saw before her I had given diclox, and so I absent-mindedly gave her diclox too. Same dosing protocol. Well she went home and had an abrupt adverse event of esophagitis. She called the clinic, I realized and documented my error, put her on a different drug. She had another adverse effect, N/V. No documented allergies, and yeah it could have happened with augmentin too....but all it takes is angry, wealthy parents and access to a dickhead lawyer as someone mentioned, and I could be sued.

Errors happen, and liability is one of the things I most look forward to leaving behind.

[lkth487]

On 2/26/2018 at 5:26 PM, mgriffiths said:

Disclaimer: I did not read every response above

It is absolutely inappropriate for a radiologist to not be reading imaging.  I used to work in ortho and while we "read" our own imaging, we always had a follow up read from radiology.  You are not a radiologist (and neither is your SP) and have rudimentary training in it at best (unless you did extra training outside of PA school).  Obviously it sucks and you feel bad, but it also wasn't your diagnosis to make either time.  That is a diagnosis for radiology.

At my clinic, I order imaging and will read it myself.  If I believe I see pneumonia, fracture, etc. I treat the problem.  But, a radiologist always reads the images.  I have been wrong a few times, missing a pneumonia where I have to call the patient and start an antibiotic, and I've been wrong starting an antibiotic when it wasn't pneumonia (pretty rare thankfully).  Often I will actually call radiology and request a verbal read so I can make a decision right then.

I'll add my "bad story:" saw an older patient for the first time on a Friday afternoon.  He was complaining of dizziness, but had no syncope, SOB, chest pain, etc.  Still did an ECG because I had a feeling and ordered some labs "stat."  ECG normal.  I never got the lab results back that day and I forgot.  Turns out the patient was significantly anemic (I think hgb around 5-6) and ended up suffering an MI secondary to his anemia over the weekend.  The hospital made a mistake not sending me the lab results, but if I had remembered that I ordered them I would have called and gotten the results and then called the patient directing him to go to the hospital - possibly avoiding his MI.  Thankfully he did ok, and has mostly recovered, but whenever I see him it is a reminder.  The patient is actually healthy enough that will be a reminder for quite some time.

For PNA specifically, I often don't treat PNA even if the radiologist calls it if I disagree with it clinically (mostly in ICU or inpatient settings).  But I realize that's a lot of liability to take on if I'm wrong*.  It's a tough situation.  But regardless of that, there should absolutely be a radiolgists reading your films. Hell, a cardiologist should eventually read all EKGs too.

 

 

*For the attending :p

[entpac]

Don''t give up on yourself. 

I agree that a new grad should never read CXRs, CTs or MRIs alone.  I started with a good primary book:  "Chest, Abdomen, Bone and the Total Patient."  This is a book of exercises in diagnostic radiology by Lucy Frank Squire, MD.  My edition is copyright 1982 and I am not sure if it is still available.  If subjective history, clinical exam and test results make you feel uncomfortable (your instinct tells you something is wrong), always run it by a colleague / sp and have them examine the patient.  

I had a patient with complaint of recurrent neck swelling (occurred maybe 3 times in 3 months) who stated the swelling always improved on antibiotics.  He was a former smoker.  After a complete and benign exam, I ordered a CT neck because I suspected something more worrisome than parotitis or lymphadenitis in the differential.  He was a no show for the CT.  I followed up on the no show with a call to his skilled nursing facility and documented who I spoke with.  The nurse said the patient told her he was not going for the imaging.  I asked her to have him sign a statement declining the recommended imaging.  I documented this as well.  Three months later he showed up with palpable level II lymph nodes and a palpable tongue base mass.  He still refused treatment and went to palliative care.  My SP stated, "you did exactly what you should have done" and “documented better than most would have. “  I still felt bad and wondered if I could have done more.  Always follow your gut instinct.

Things will get by you, but we are entrusted to give the best care possible and always keep the differentials in mind.   It will take a few years of experience for you to know what you are comfortable with.  Meanwhile, rely on your SP and have a back up (a trusted colleague). 

 

 

[jwells78]

Man that sucks, sorry.

 

1. Always have SP over read your cxr, especially this early.  They can be difficult to read and correlate until youve read a few hundred.

2. Like EMED said-  have an approach; (abcdef or I like : ABCDLMP- airway/bones/cardiac/diaphragm/lungs/mediastinum/pleura)

3.  This happens.  Do your best to not let it happen often

 

Saw a retired cop with hip/thigh pain in ED about 7 years ago (newer PA at the time).  Pain was indistinct, non radiating.  Pmh renal CA, tx'd and in remission.

xrays of his hip and l-spine were normal.

Sent him home with conservative care.

He came back 2 days later with a fractured Femur same leg after he bumped into his dresser:  pathologic fx with a huge mass mid-femur.

 

I will never forget it, and I will keep that f$$k-up in the back of my brain as a reminder.

 

-J

[LAPA259]

Just wanted to say thanks to all of you for your words of encouragement. My SP is now double checking all of my XRAYs at the end of the day. He does not hover, but allows me to attempt it myself and then rechecks in his separate office at the end of the day so we both feel more secure. Thus far I haven't made a bad call! I've caught two cancers since the time I posted this and though sad, I am very happy that I am working towards becoming a better PA. 

Thanks again

[Jofriend]

LAPA259 - This is a result of really caring about your patients.  If you did not, you would blow it off.  Keep going!  You have what it takes. 

[jmj11]

I came to this late and only skimmed all the responses. My point that I'm going to make is that this happens to all of us, yet, it can be in the back of your mind for the rest of your career. Like said above, learn what you can.

I too never read MRIs or any film without a radiology read as well. Never. That read would come within 24 hours or within 1 hour if I had a concern. I've walked MRI films over to a neuroradiologist and ask him to look at things.

Regarding the enduring influence of these situations, early in my career while working in an Air Force hospital, I missed my only cancer that I'm aware of. A man came to sick call with a new onset of stomach pain. I went over his GI history and started him on a gastritis, ulcer cocktail and a follow up in 1 week. He came back with no improvement. I scheduled him later that week for our general surgeon for a GI work up. Unbeknown to me, the surgeon decided to take a 30 day leave to do a mission project in Mexico and he had no back up so his office schedule the man about 7 weeks out. It was two months later that I heard from the surgeon, after the GI work up, that the man had a late stage pancreatic cancer. I felt horrible, yet I don't know of any mistake I made. I wish the patient had called and told me his appointment had been bumped and then I would have worked on sending him to a civilian surgeon.

In closing, I could easily write a book on the number of missed cancers I've found in patients who were just dismissed by their MD or DOs. I've found serious CNS disorders in patients who had just visited with a neurologist and was told their symptoms were functional. I watched in horror as an arrogant infectious disease doctor, who had a beautiful intern working with him that he wanted to show-off to, drown a patient in IV fluids while treating her TB. The intern was in charge of the IV and he kept saying in a cavalier way, "You can't over hydrated these young sick patients."