45. The Error
You can’t miss anything. As doctors, we can never miss anything.
Of course, I’ve missed some details in my life as a doctor, but thankfully none that directly threatened a patient’s life. Well, at least not yet. But I’ll never forget the story Lucy, our attending, told us one day after rounds. We were with a delicate case we hadn’t figured out yet but the surgical team wanted to take it to the OR and figure it out on the table. Lucy strongly discouraged that idea, and later we found out why.
‘Surgery is a bad idea.’ Dr. Collins told us when the surgery team left. She had already made it clear that she thought the surgery could wait and they ended up agreeing with her. She was very persuasive when she wanted to. ‘I once had a case that made me realize how dangerous it can be to operate if we are not sure it is safe.’
We nodded for her to continue, and then she told us a story that makes me slightly scared of being a doctor.
It was a young man, in his twenties. He found a nodule in his neck and went to his primary care physician. After the appropriate workup, he was diagnosed with thyroid cancer and was transferred to Brooklyn Hospital Head and Neck surgery department. They ordered a consult with the internal medicine team just for them to check if the guy was doing fine.
‘And boy didn’t he look great.’ Lucy said with a sad smile. ‘It was my second year as an attending, and I was honestly tired of following up on these surgery patients. We didn’t have much of a saying in the assessment plan after all.’ She got up and poured herself a cup of coffee. ‘Either way, I made the worst decision in my life as a doctor that day.’
She then told us that she went to see the patient and didn’t find anything wrong with him. He was a healthy person besides the thyroid cancer and his labs were unremarkable. She would definitely clear him for surgery although she didn’t have the time to say anything either way since they took him to surgery that same afternoon before discussing the case with her.
‘But I overlooked.’ She said with a very serious tone looking at me and Peter. ‘We all overlooked. The surgeon, the anesthesiologist, me. And it cost that man his life.’
At that exact time, a nurse came in and called Lucy with a certain urgency and she left us with this cliffhanger. Peter and I were left wondering what they could possibly have missed in that case.
‘What do you think happened to him?’ He asked me.
‘I am honestly clueless.’ I said with a worrisome tone.
‘Do you have any guesses on what we could have possibly overlooked?’ Lucy asked as she came back through the door and we both said no. ‘We overlooked the kind of tumor he had.’ We looked at her confused.
‘The kind as in the histological kind?’
‘Yes.’ She smiled sadly. ‘Now what difference would that make?’
‘Gravity of the surgery? Metastasis?' Peter guessed.
‘Well we do have to take those under consideration, but that’s not what I am talking about now.’ Lucy started to enjoy the challenge she was proposing to us. ‘What else?’
‘Some metabolic derangement? Like hypo or hyperthyroidism?’ I guessed now.
‘His labs were normal, including his thyroid function.’ Dr. Collins reminded me. ‘But metabolic derangement is not that far. Think of the kinds of cancer he could have.’
We thought about it for a moment. Peter looked at me and we started to list it out loud.
‘Papillary, follicular, anaplastic, medullary...’
‘Medullary?’ I guessed.
‘Go on.’ Lucy said.
‘It could cause hypercalcemia because of parathyroid hyperplasia if he had MEN 2A.’
‘You’re getting closer, but that’s not our biggest concern.’
‘Well, medullary thyroid carcinoma is associated with Multiple Endocrine Neoplasia type 2.’ She nodded for me to continue, but despite the fact that I thought of the syndrome, I still couldn’t figure out how missing that could threaten the patient’s life. I went on anyway. ‘It’s a syndrome characterized by medullary thyroid carcinoma and pheochromocytoma, along with some other features depending on the subtype. MEN 2A has parathyroid hyperplasia and MEN 2B has marfanoid habitus and mucosal neuromas.’
‘Very well, Lisa. Nice theory you have there, now why does that matter?’
A few seconds passed until Peter saved me with the explanation I couldn’t think of.
‘An undiagnosed pheochromocytoma can cause anesthesia-induced hypertensive crisis.’ He said.
‘Exactly. This patient had no symptoms of pheo, like intermittent headaches, hypertension, and tremors. But we still should’ve paid attention to the fact that his tumor could be related to it.’
‘So did he have a hypertensive crisis?’ Peter asked with curiosity.
‘Not only that, Peter.’ Her tone was sad again this time. ‘His hypertensive crisis caused a massive brain bleed. He stayed in the ICU for months and ended up dying from a pulmonary embolism.’
That story stood with me. Dr. Collins is such a great doctor and even she overlooked that detail. It’s crazy to think how hard this job can get. I got home and told it to Jax so I wouldn’t be shocked alone.
‘Remind me, Lisa, why did we choose this job?’ He asked me
‘Not a good day to answer that, Jax.’ I got up from the couch. ‘Ask me again tomorrow.’
...
Want to read a real case of Multiple Endocrine Neoplasia type 2 (MEN 2)?
http://www.ijcem.com/files/ijcem0021871.pdf
Want to read more about Multiple Endocrine Neoplasia type 2 (MEN 2)?
https://rarediseases.org/rare-diseases/multiple-endocrine-neoplasia-type/
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