Question for other docs, only, please?

Thank you for the question. And an excellent question at that.

I respectfully both agree and disagree with the distinguished responders above.

First, I appreciate your professional dilemma in not wanting to stir up a hornet’s nest, so to speak. It’s an uncomfortable position professionally, not mention the impact it has on your conscience. You know, I tell all of my resident doctors and students that if they go to bed feeling disturbed about a case, you know that you’re damned good doctor.

Secondly, I do agree with you that in clinical medicine, missing a SBO is difficult to achieve, because in the appropriate circumstances, it does not take much for a clinician to (1) think of the possibility (2) document on the chart of record that he/she considered the possibility and (3) and it takes less effort to order a KUB series/CT. A diagnosis such as this cannot be missed, no more than bacterial meningitis should be missed. However, I too, am curious about the circumstances and clinical decision making leading up to the patient’s death. Although I’m assuming that you already have, I would strongly recommend requesting the entire chart of record and comb through each and every progress note to study the assessments and decision making of all the primary physician of record and any and all consultants. Did the treating physicians document that they at least considered SBO? If so, did they investigate appropriately? Perhaps they did make a diagnosis but other extenuating circumstances prevented timely surgical intervention (i.e., septic shock, family’s wishes for DNR/DNI). If after reviewing the chart you believe that there is incomplete documentation or you have doubts about the decision-making, then interviewing the primary doctor would be in order. However, before you do interview the physician, I agree that briefly discussing the matter with risk management on how to proceed in terms of substance and style would be wise. Then, if after interviewing the doctor, you still feel that negligence permeates the case, then I would discuss the case further with risk management/hospital medical board and let them handle the matter.

Finally, from a pure academic standpoint, I agree that this case may be appropriate for a M&M conference at the hospital of origin to educate other clinicians on the pitfalls of such a case. Unfortunately, in medicine, at least from my experience, teaching cases too often focus on positive outcomes/cases when in reality, it is the difficult cases/poor outcomes that have as much (or more) to teach us about medicine. This is how our profession has evolved and how medical knowledge & practice have been shaped through the centuries.

Food for thought -

Army boy admitted for Lt knee pain. OE - no redness, not inflammed. CBC normal except TWBC 11.3 (roughly). BUSE normal. X ray normal. MRI normal. 3 days later, this boy died. Diagnosis : GAStrep.

This case becomes a court case.

Pathologist (ME) commented : missing GAS is unforgivable.

When the MO was called to testify, he says, "this boy has been admitted for 6 times over the past 2 yrs.

1. c/o haematuria but no pathology found. It was accidentally noted, patient added blood to the urine specimen from a scratch wound.

2. c/o haemoptysis. Again, no pathology found.

3. c/o headache. All investigations, incl a series of test on CSF, are all normal.

4. c/o abdominal pain. Similarly, no pathology found.

5. c/o back ache. Same, no pathology.

Boy referred to psy. He admitted all those complaints doesn't exist. He thought he can get off (army duty) with medical excuses.

Unfortunately, this cry wolf died on the 6th admission.

Negligent of the docs? 'Yes' you may say.

Human's nature to doubt someone who's a cry wolf?

Any possibility the deceased also cry wolf? As a result missed diagnosis? I know many here will start to argue on this, and not agree and won't accept such things! (and will bring in code of conduct, professionalism.... Let's put all that aside first. )

Sometimes in life, a lot of things are in the grey zone. One should not jump to conclusion. Could there be some other issues involve? You didn't get to ask the deceased. Just purely based on autopsy's finding. What about patient's factor?

Differential diagnosis for small bowel obstruction is not very clear cut also. So how can you say it's "unforgiveable"?

By notifying, the doc who made the diagnosis will sure be in trouble. Your intention may be good, so as to avoid similar incidence. The impact can be drastic.

By speaking to the doc directly, you can get a clearer picture. Decide from there, as to notify or not. Your judgement will then be more fair. And your conscience, will not be pricked years down the line.

You have the opportunity to use the autopsy as a teaching experience. Why not schedule these two cases as CPCs, asking the two physicians involved to present their respective cases? Schedule a learned staff member to discuss the cases, then you present the finaldx.

Additionally you should notify your department head or follow the guidelines in your hospital by-laws, rules and regs. If the situation remains unclear, discuss it with either the chief of staff or the hospital CEO. There is a famous case dating back 30 years or so where a hospital and some doctors on staff were successfully sued because they looked askance at the grossly substandard performance of one of its staff surgeons. So, if the physicians involved were staff members, you need to bring these cases to the attention of the appropriate parties. Hospital politics being what they are, you should otherwise minimize your role as whistleblower unless no action is taken.

I'd start with risk management. They may be able to best advise you as to how to approach the physicians in question from a standpoint of education/information as opposed to blaming and confrontation. That also keeps the communications protected from discovery in the event of a lawsuit.

Do these docs have privileges at your hospital? The hospital's medical executive board take care of notifying the physicians, and it can then be up to them to take it further if necessary. They may also know of other complaints or instances of questionable care.

None of us wants dangerous physicians practicing, and we all know some who fall into that category. However, there may be extenuating circumstances that you don't know about - maybe the patient was given appropriate advice but chose not to follow it? Maybe the insurance company refused to cover a necessary admission?

If I was in your situation, I'd pass the information along to the appropriate administrative bodies (thereby clearing my conscience) and let them do what they get paid to do.

My condolences on your choice of specialty. If I had to do five autopsies, the sixth would be my own.

I'd discuss it with the treating physicians first, and then with RM. There's something to be said for the British system, in which pathologist have spent some time as GP's before they specialize. If you've treated enough puking people, you find out in a hurry that partial SBO's aren't always easy, and it's quite possible your patient's complete obstruction wasn't at all straightforward at the time of the exam. Think back to what you learned in medical school: your exam isn't complete until you've done both your history and your physical, and you haven't done a complete history until you've spoken to the physician.

FinalDx, you must be asking us because your responsibilities in this specific area are not clearly defined / mandated (I assume you are a jurisdiction-appointed medical examiner, yes?).

I would certainly inform the clinicians as a matter of professional etiquette.

If you are asking the question "Should I report this to the medical board?", then the answer is invariably yes.

Your job is to determine cause of death, not to make legal / administrative judgements.

If you dont want to get someone in trouble then talk to whoever missed it. Otherwise go to a superior with the issue. Thats how I would go about it.