DISCLOSURE: A LEADER WALKS A THIN LINE

Mike Radzienda writes…

A man presented with urinary retention and a UTI. He also complained  of mid -thoracic spine pain that was sub-acute. His PMD treated him with antibiotics but his symptoms persisted. He had worsening urinary symptoms and developed lower extremity weakness. On presentation to the hospital, he was admitted to the neurology service and was found to have spastic paralysis of his lower extremities. Exam at that time showed marked upper motor neuron sign in his legs. A brain MRI was read as normal. An MRI of the spine revealed no evidence of spinal cord disease but the thoracic images were not interpretable due to motion artifact. The neurologist commented in his note that the MRI of the spine was normal. The following day the MRI was redone and reported out as, “a retro-pulsed disc is compressing the spinal cord at T-8 and there is enhancement in the anterior portion of the cord adjacent to the area of cord flattening.”

Subsequently, the team never commented on this finding in the record.

The patient was treated with pain medications and had an EMG. During the hospitalization he suffered a partial seizure. An EEG did not reveal a focus.  He was started on anti-seizure medication. The patient had marked weight loss over the month since his symptoms started. He was discharged home on high dose corticosteroids and with an indwelling urinary catheter . He was given no formal diagnosis.

While on prednisone, the patient’s weakness improved but he did not return to normal.  After the prednisone was stopped his weakness returned and he developed pneumonia. On presentation to the hospital for HIS pneumonia, he was given broad spectrum antibiotics. His pneumonia improved but the patient developed C. difficile colitis complicated by megacolon.  He underwent an emergent sub-total colectomy with colostomy.

Three months into the illness, the diagnosis of critical illness myopathy was made after a repeat EMG. The patient’s BMI dropped to 15. He had anorexia and received a PEG tube. He was discharged home and re-admitted twice for worsening weakness, and pain. Subsequent admissions and work ups did not reveal a unifying diagnosis. The patient continued to complain of severe back pain.

Due to continued decline and, at the request of the patient’s spouse, he was transferred to an esteemed medical center to be worked up for a second opinion.  After a month at the new facility he was sent back to the primary hospital with no formal diagnosis except critical illness myopathy.  The patient was told that he had a mysterious diagnosis yet to be defined in the medical literature.

On return from the outside facility he was admitted to my service.  This man looked like a prison camp survivor.  We reviewed the charts and data and told him that we had made a mistake. On prior admissions we had missed his initial MRI finding which showed a spinal cord injury.  As well, this initial MRI was not sent with him for the second opinion.  We gave him the copy of the MRI report for his records.

We also diagnosed him with severe hypogonadism and started him on testosterone replacement.  When we inquired more about the weight loss, he mentioned that he had always been thin and was a poor eater. He also noted that this is why he chronically smoked marijuana (something he had not revealed because he was never asked). Without the pot, he had no appetite.  He had not had any pot since his initial presentation 5 months earlier. We started him on dronabinol  and the next day he was devouring peanut butter and celery sticks.  His tube feedings were stopped.

I told him and his wife that I was sorry for all that he had suffered. Was sorry enough?

He had been evaluated by several of my colleagues prior to my evaluation.
What is my ethical duty to this man?

He turned 40 during this admission. I am 40. I could not bear to think what it would be like were I in his position.  I would want some type of compensation, retribution, satisfaction,…something.

Did he connect the dots? Did he realize what an egregious error this was?  Would he seek satisfaction in the courts?  Was it my duty to notify him that he has an open and shut malpractice case?  That my colleagues had contributed to this mishap?  I discussed this with counsel and was advised to disclose only the error, not my opinion or editorial.

Last week I bumped into the patient in the hospital cafeteria.  He was in rehab and was doing well.  He thanked me for closing the loop for him and was at ease to know he did not have a strange, yet-to-be-discovered disease.  I shook his hand and slipped some caramels into his pocket.

I think about this every day and I am not satisfied with myself.

What would you do?

2 Comments

  1. Jack Percelay on May 18, 2010 at 10:50 pm

    Mike,
    There was a great presentation in DC about the disclosure policy of the University of Michigan and how full disclosure has reduced their overall malpractice expenditures.
    So, IMHO, I think you have an obligation to explicitly state that the report on the initial MRI 3 months ago was missed. Apparently this was done. You have met your ethical responsibilities to the patient; you are responsible to improve the system so this doesn’t happen again.
    I also think your hospital should make sure the patient is reimbursed for any out of pocket expenses due to the delayed diagnosis. The advice you were given is a gamble that this person will not sue. He still has plenty of time to file a claim. The evidence suggests that a more proactive less ostrich- like approach would be more cost-effective overall.

  2. Mike on May 19, 2010 at 7:51 am

    Thanks Jack.

Leave a Comment