A missed call

It was finals week in December 2009 when Alex Halstead, a 19-year-old UGA undergraduate, felt a stinging pain in her lower right abdomen. She was cramming for a final the next day and it was 11:30 at night, but she was worried that she might have appendicitis.

Her roommate delivered Halstead to the emergency room of Athens Regional Medical Center by midnight, where the doctor on duty was worried enough to admit her.

After recording her vital signs and hooking up an IV of painkillers, he gave Halstead what she remembers as a “metal-flavored milkshake.” This was a contrast agent that makes it possible to visualize abdominal structures – such as a swollen and inflamed appendix – using a CT scan.

The CT scan, however, showed nothing out of the ordinary.

Based on the scan, the doctor ruled out appendicitis and decided that Halstead instead had an ovarian cyst, a much less threatening condition. She’d had one before and women in her family were plagued by endometriosis, which can also cause intense abdominal pain.

As it turned out, he was wrong.

Looking back, the doctor appears to have made a type of medical error known as “premature closure,” said family practice expert Mark Ebell, a member of the U.S. Preventive Services Task Force and a professor in UGA’s College of Public Health. This type of mistake happens when a doctor reviews the patient’s symptoms and makes an initial diagnosis without adequately considering other possibilities.

In this case, the doctor jumped to a conclusion based on Halstead’s medical history and the CT scan results.

He sent Halstead home with pain medication and recommended that she contact her gynecologist in the morning. Her alarmed mother raced to Athens early and drove her daughter to the office of gynecologist Frank Lake, who practices in Gainesville at Northeast Georgia Physicians Group, which is affiliated with Northeast Georgia Medical Center (NGMC).

When Halstead described her symptoms, Lake said it was “textbook appendicitis.” He didn’t put much stock in the CT scan, which inevitably misses a certain percentage of appendicitis cases.

“The mistake that can be made is that we rely too much on our diagnostics,” said Lake.

Lake immediately called a colleague at NGMC for a surgical consult. When Halstead arrived at the hospital, it didn’t take long for the surgeon to identify the cause of her pain.

“He hit the bottom of my heel, and I started immediately vomiting and crying,” Halstead remembers.

Even a slight jolt can cause someone with acute appendicitis to vomit, so the doctor rushed her to surgery. The surgeon had used a simple, physical maneuver – not fancy equipment – to identify a potentially life-threatening problem.

That said, Lake readily acknowledged that he and his colleague may have benefited from the passage of time. Halstead’s condition almost surely worsened overnight – making it easier for him to identify.

Many hospitals now use checklists and other protocols to keep surgeons from operating on the wrong limb or patient, the types of mistakes regarded as “procedural” errors. Systematic efforts to reduce errors in thinking – such as misdiagnosing Halstead’s appendicitis – have lagged behind, said Dr. Scott Richardson, campus associate dean for curriculum at the GRU-UGA Medical Partnership in Athens, Ga.

Diagnosis happens in the mind of the physician, not out in public where others can see what’s going on.  This complicates the challenge of developing regulations or policies that prevent errors. But Richardson sees two areas that policy shifts can target.

The first is noise.

Emergency rooms and intensive care units are incredibly noisy places, making it difficult for doctors to detect subtle clinical symptoms. For example, the sounds of a quiet but dangerous heart murmur can be drowned out by the cacophonous environment of the ER.

This past November, CBS News reported that a hospital in Ontario tackled noise pollution by installing sound-absorbing ceiling tiles, creating more private rooms and moving overhead loudspeakers to the hallways instead of over patients’ beds.

Richardson also believes the reimbursement system needs an overhaul.

Under the current system, doctors can be reimbursed only for time and procedures linked to a specific billing code, which reflects a diagnosis. But sometimes a doctor can’t make an accurate diagnosis after the first meeting with a patient.

This forces physicians to put a label on a condition before they know the answer, said Richardson.

“Some label has to be applied,” said Richardson. “That label develops a kind of momentum, a life of its own, and that tends to narrow further thought.”

In the same way, relying solely on imperfect technology, like the doctor in Halstead’s case, can prevent doctors from using their clinical skills and common sense to figure out what’s troubling the patient.

“If it walks like a duck, and it quacks like a duck, it’s probably a duck,” said Lake.

Appendicitis afflicts nearly seven percent of people during their lifetime and is misdiagnosed between 20 and 40 percent of the time, according to the Agency for Healthcare Research and Quality.

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