Day Twenty-One: Haunted by the Past

It was a packed day today. So packed, in fact, that I’m going to split the events into two posts.

Today was the monthly Morbidity and Mortality (M&M) report. It is run much like the way they do it in the U.S., where a senior resident has the duty of presenting the cases of patients who experienced harm (morbidity) or death (mortality) due to medical error. M and B, the two ID fellows, were particularly interested in hearing today’s presentation, since the main case that was going to be presented was about the patient with the odd bacteremia (otherwise known as the potential case report publication).

In short, it was the most painful M&M I had ever participated in.

The senior resident presenting the case was R. I wasn’t clear on whether or not he was the senior resident on call when the patient was admitted, but in any case, his presentation of the history and physical was very, very sparse. This was the very kid that M, B, and I seen over Khmer New Years, who appeared to be malnourished, dehydrated, and otherwise in very bad shape. Yet, to hear the resident’s presentation, it would have seemed like the patient wasn’t that bad off at all.

So as not to repeat myself, I’m going to include this link in case anyone wants more background on the actual case. But suffice to say, the resident neglected to mention a lot of important details. Other than the admission physical exam, which appeared to be extremely brief, it seemed that the child had been left alone with fairly little monitoring for a day before someone picked up that his heartbeat was faster than normal. In addition, when M, B, and I examined the patient, we found him to be disturbingly lethargic, as well as with evidence of oral thrush. Typically, such details would be important indicators of the severity of the patient’s illness; however they were not present in the resident’s M&M report.

At the end of the report, M actually raised his hand and informed the resident about the oral thrush we saw when we examined the patient, saying that this finding may indicate that the child was immune-compromised, perhaps due to HIV. This comment led to a series of reprimands by Dr. L, who gave the residents in the room his usual impassioned lecture about the importance of taking a good history and physical.

I did not get to stay for the entire conference, since I was scheduled to accompany the home care staff on a visit to check up on patients out in the rural areas. But later on, M came to find me and said that despite the intriguing bacterial find in this patient, he really did not feel comfortable publishing a case report on the patient because of the numerous gross errors that occurred in the general management of the patient’s care.

My feelings were similar to his. Inside, it was still hard for me to accept that this patient had literally died because he was admitted during a holiday—a time during which everyone’s guard had been down. And as much as I loved the thought of writing about interesting microbiology, I hated the thought of this patient’s sad hospital course haunting AHC’s otherwise good reputation in print.