Here’s something that should come as a shock to no one: bouncebacks are dangerous. Patients are distressed or ill enough to feel that whatever was done for them the first time, wasn’t enough. Beyond just managing patient expectations, you have to ask yourself: “What could have been missed?” Khan’s Commandments dictates that in most instances, when a patient returns a second time for the same complaint, the workup should be doubled. A negative x-ray for constipation? Get a CT scan. A negative CT scan for back pain? Consider an MRI. Reassurance and discharge for a child with gastroenteritis? Consider IV hydration and lab tests.
Incrocci v Family Care
Nicole Incrocci (see how much worse it seems when you give ‘the patient’ a name?) was a 15-year old girl who was minding her own business when a snake bit her on her leg. The swelling progressively worsened over one month. She developed a cough and went to an ER where she was diagnosed with pneumonia. Antibiotics were started and she was sent home. Over the next ten days, she had three additional visits to a clinic before ultimately being admitted to the hospital for ‘worsening pneumonia’. As an inpatient, her condition continued to worsen and antibiotics were changed around. She received nebulized breathing treatments, oxygen, and anti-pyrretics. The next morning she complained of chest pain and collapsed in the bathroom. The differential was [finally] broadened and CT angiogram confirmed the finding of a saddle embolus. Shortly after, she went into cardiac arrest and died. The jury provided the family with $6.7 million.
Take-home points:
If a patient is not responding to treatment, consider an alternate diagnosis. Don’t expect the same thing to work when it’s already demonstrated that it won’t.
Maintain a broad differential diagnosis. Especially when the patient is failing to improve.
Avoid anchoring bias. Even if the x-ray reads ‘infiltrate’ it may actually be an ‘infarct’ masking as an infiltrate. Anchoring on to one particular diagnosis and failing to adjust your approach to diagnosis and treatment is a setup for failure.
