MISSED CANCER DIAGNOSIS, new grad feeling terrible

[Reality Check 2]

We have all "missed" something or had a profound diagnosis stick with us and make us hypervigilant.

A man over 60 had new onset headaches. I chose imaging - an MRI because it was not acute and a CT would have said "consider MRI for further evaluation". What the dept didn't tell me was that he refused the first two attempts to schedule stating he has to "be put out completely" to get in an MRI - we don't do that at my site. It took 4 weeks to get him in an MRI. No other symptoms - no constitutional changes. Blood pressure was ok, nothing struck me as whacky.

Metastatic melanoma from 10 yrs ago - he had NEVER told me he had a melanoma removed from his back. 

He died 3 months later. 

Nothing I did or did not do would have changed his outcome, unfortunately. Melanoma sucks.

But, for the next 6 months, everyone with a headache got an MRI................ yep, call it paranoia. The chances of finding that again are slim. 

Another guy - mid 50s, heavy smoker, drinker, drug use - noncompliant HTN, no straight answers - lots of lies. Stopped his PPI - timeframe unknown - called for refill. Gave him ONE refill of PPI and requested appt. He did not come in. He did not request a refill. Fast forward 3 months - he and his ex started calling demanding an asap appt. He showed up looking like poo on a stick - vomiting, doubled over, lost weight. 

Hx of marijuana emesis and drug use - his symptoms did not surprise me. I sent him to UC due to dehydration and inability to hold anything down. They did a belly xray, IV fluids and sent him home. I thought he deserved an admit - I was outvoted by a grouchy UC doc. 

Somehow ended up with a chest CT - not sure why. Lung disease from smoking but "no acute findings".

A GI consult was placed. No answer to phone calls. A few weeks go by. Don't hear from him. Can't find him.

Showed back up at a local ER and finally got an EGD. Big old tumor wrapping the lower esophagus from the stomach. Going back to the Chest CT - they can see a faint shadow of "something". 

He has stomach cancer.................. died 2 months later. Ex threatens to sue.

Combination of noncompliance and complicating factors. Could we have saved him? Doubtful.

It changed how I preface conversations - "GERD can cause cellular damage. A a smoker, drinker, insert bad habit - you are at higher risk for cancer. I recommend an EGD within 30 days and stay on your PPI. PS - quit smoking, drinking, drugs".

Does everyone NEED an EGD? Probably not. Will I still recommend and order one - probably. 

We are guides. We can give advice and do our best with what information is given to us. We can't force people to answer the phone or go to appts or stop smoking or drinking or doing drugs.

We live in a litigious society. Document everything. Give good advice, be sincere. Do your best. Learn constantly.

 

[ventana]

Medicine care is a cruel partner.  
 

you do good and catch something.  Get the professional high of a great Dx.   
then be prepared for the good old smack down.  You miss something or do something not 100% and it blows up.  Yup that is medicine and the human being.  

[lancer_dancer01]

Yup we all will miss something, definitely at higher risk depending where you practice. I had a 33 year old previously healthy male present with ear pain at the UC. Exam was consistent with OM and there was some lymphadenopathy which I chalked up to the infection. He came back a few weeks later with more sinus pain and pressure, HA, and some ear pain. I did think possible resistant infection or new sinus type infection so treated with longer course and steroids and recommend f/u with PCP. Well he finished those and still wasn't getting better, saw my partner who sent him to the ED as he was concerned about a deep space neck infection. He ended up having nasopharyngeal cancer and died (obviously it was quite advanced so not sure anything I could have done different would have led to better outcome). I play through that case a couple times a week. The big thing is to learn from it and make the appropriate changes so it doesn't happen again.