Tuesday, March 16, 2010

Mis(sed) diagnosis

I have lots of interesting stories to tell - about great saves, surgical miracles, and other "I'm a fabulous veterinarian" tales. Instead, I want to bring attention to a problem all ER doctors (and GPs too) struggle with - the time crunch.

A couple of Saturdays ago, I was swamped with cases. In the midst of this, I was confronted with an almost 200 pound patient. He had developed swelling of one of his front legs and was limping badly (almost non-weightbearing).

At first glance, I thought an orthopedic problem. Palpation of the leg did not elicit any specific areas of discomfort. Further, the swelling of the leg was not centered over a joint or particular area. The entire antebrachium (forearm) and carpus (wrist) were swollen and slightly warm to the touch. I could not find a puncture wound anywhere. His temperature was 104.7...but he was 200 lbs, limping terribly, and we'd had a spurt of spring-like weather that day. He'd walked almost a mile on 3 legs to get into the car, and he was panting very heavily. I attributed the high temperature to heat/exertion stress. It improved to normal with acepromazine and hydromorphone, something a true fever usually won't do.

I wrote up sedation orders for him so that we could take xrays, and turned to the other 7 patients awaiting my attention.

When I reviewed his xrays later, there was no evidence of a fracture - just diffuse swelling of the leg.

In any other circumstance, I would have thought about cellulitis/abscess formation (infection of the tissues below the skin), but I was overworked, overwhelmed, and busy. The dog was otherwise doing fine at home - eating, drinking, and attempting to walk.

I dispensed pain medications and advised the owners to follow up with their vet on Monday if there wasn't noticeable improvement.

Monday came round, and the owners went to their veterinarian because the dog had not improved, and the leg was significantly more swollen. Bloodwork revealed a white blood cell count of 60,000 (!!!). Normal for a dog is between 5,000-17,000. The vet diagnosed cellulitis and started antibiotics.

Where was my mistake? As I review the case in my mind, there are several.

1) I was biased in my thinking. A 200 lb outdoor dog with sudden onset of swelling in one limb, I assumed orthopedic or soft tissue trauma - based on many other patients I see.

2) I assumed the 104.7 temperature was heat exertion/stress based on the fact that it improved with sedation and decreased respiratory rate. With the combination of the swollen leg - I should have been thinking infection (although I'm still not sure whether it was a true fever or not).

3) Busy - I was too busy and overloaded at the moment to take a step back and really assess the case. In my head, I had put the pieces together: diffuse swelling of the leg not centered over one particular area, acute lameness, no specific areas of bad pain, and a possible fever...these equal cellulitis...or at least, they should have!

The dog is doing fine on his antibiotics, but this has been bugging me for the entire week. I had intended to call the owner on Sunday and relay my suspicions about cellulitis, but then I got swamped again, and by the time I looked at the clock, it was well past 11pm. I had fully intended to ask them to come back in for a free re-examination....and then...time got away from me.

It's frustrating when this sort of thing happens, because the patient doesn't receive optimum care. The owners feel cheated, because they spent $300 to see me, and I didn't make a diagnosis. I feel like a failure as a doctor because I was tired, overworked, stressed, and made a mistake. Nobody wins in that situation.

1 comment:

Andrew Carr said...

Everyone messes up, no matter how good they are at what they do. This experience will help mold you into the best Dr. you can be. The good times are made that much better by the bad. You are smart, and a good Dr. Don't let it get you down.