My Greatest Mistake

A call I never made

BMJ 2004; 329 doi: http://dx.doi.org/10.1136/bmj.329.7480.1496 (Published 16 December 2004) Cite this as: BMJ 2004;329:1496
  1. Anil Pandit, physician (anilpanditrules{at}hotmail.com)1
  1. 1 Kathmandu, Nepal

    When I was working as a resident in Patan Hospital, Kathmandu, on one busy on-call day, I was called by the emergency room resident to see a patient with possible myocardial infarction. The patient was being treated for congestive heart disease and had fainted that morning. His vital signs were stable and an electrocardiogram showed ST segment elevation and widened QRS complex, which were new findings. I made a quick diagnosis of acute myocardial infarction while chemistries were pending. I called an intensive care resident to find out if any beds could be arranged, but no beds were available. I decided to transfer the patient to the Heart Centre in the other side of the town. I rang the Heart Centre and made arrangements and finally transferred him, escorted by an intern. Later the blood chemistries came back. He had potassium levels of 6.7 mmol. The typical ECG findings were due to hyperkalaemia, probably not to myocardial infarction. I sent the report with the patient and forgot about him that day, as I was very busy.

    Later my assistant informed me that the patient I had referred had died of an arrhythmia. The Heart Centre had told my assistant about the patient's death. He said only that I could have telephoned the centre about the hyperkalaemia. Then he said no more and went away. That was enough for me. A gush of electric current passed from my head to my feet; I started sweating and my heart started racing: I had made a serious blunder; what kind of doctor was I? When it came to transferring the responsibility of the patient care from my head to others, I was doing all I could. I was making phone calls, wherever I could. But when it came to real patient care I was so indifferent. I acted as if once the patient had left the hospital, it was not my duty. I told myself that my attitude, knowledge, and skill cost a patient's life and I was deficient in all those qualities that a doctor should have.

    The incident taught me the meaning of that most talked about topic, the doctor-patient relationship. The doctor-patient relationship doesn't end when the patient leaves the physical boundaries of our care. Most of the time, it haunts me that if I had given a call, the patient's life could have been saved. These thoughts lead to a concept of universal doctor and universal patient, analogous to health and disease respectively. There are no individual doctors or individual patients. Because I identified myself as a different doctor from those in the other hospital, I thought the patient was no longer my responsibility: there was somebody else to look after him. Had I thought that he was just a patient and I was just a doctor, wherever he was and whoever was treating him, this incident would have been avoided.

    Footnotes

    • Competing interests None declared.

    • True confessions

      In October Minerva asked readers to submit their tales of clinical, career, or other mistakes, for publication in this issue. First to respond were Dave Sackett and Richard Smith, followed by others, some of whose confessions are printed below. You can see all the responses and add your own contribution on bmj.com (http://bmj.bmjjournals.com/cgi/content/full/329/7474/DC3)

    View Abstract