Friday, December 08, 2006


The baby looked pretty good when I examined him on morning rounds, but his abdomen didn't feel quite as soft as I thought it should. It wasn't distended, though, and he had been tolerating his feeds, which generally means a baby doesn't have significant abdominal problems. I just wasn't quite satisfied with the feel of the abdomen and asked the nurse not to feed him while we observed it. About an hour later the nurse asked me to look at the abdomen once more. Again, it didn't look bad, wasn't distended or anything, but just didn't feel quite right. We obtained an x-ray and bingo, there it was: free air in the abdomen, air that should have been contained in the intestines but wasn't, indicating that he had a hole in his intestines.

We got the pediatric surgeons involved as soon as possible. They operated, found a spontaneous intestinal perforation, and removed a very small portion of intestine. The baby was pretty sick after the operation but gradually improved.

I felt pretty good, a little smug even, about picking up the problem early, before the baby developed feeding intolerance and worse abdominal problems, but then I reviewed a chest x-ray taken two days previously. There, in the little bit of abdomen that showed on the chest x-ray, was a little patch of free air. I should have noticed it then. I had missed free air two days before, letting the baby go for two days with a perforated intestine.

I felt terrible. In fact, even as I think of it again now, I still feel lousy about it. Like most doctors, I hate making a mistake that harms a patient. Sure, the baby survived, but if the perforation had been noticed two days earlier like it should have been, maybe the baby's post-operative course wouldn't have been so rocky.

The problem is that there is no good way to comfort yourself when you make a mistake like that. I try to do so by noting that the radiologist - one of the best at our hospital - also missed the free air on the chest x-ray, but that doesn't help much. I still should nave noticed it. I know that when you get a chest x-ray you should look at the chest on it last, noting the abdomen and bones first precisely so you won't miss something like this. I just blew it, and there's no getting around it.

I tell myself that as long as I learn from this, it's not completely terrible, and I did learn from it. For the next several months you can be sure I'll be checking for abdomen abnormalities on all the chest x-rays. But then, being human, my memory will start to fade, and a few years from now I might be tired or hurried, and when I get a chest x-ray not look at the abdomen....


Blogger Ex Utero said...

Hi Neo Doc,

you could probably anticipate that I would have a comment about this post. Don't feel bad. Every one thinks these perforations are easy to catch, but our data suggests that as many as a quarter of all cases are occult (see abstract below).

More than that, you're in good company when it comes to neonatologists missing / misdiagnosing this disease entity. The Vermont Oxford data base routinely mis-diagnoses this disease. They will not allow their data recorders to list a diagnosis of intestinal perforation into the data base unless it is proven by autopsy or surgical visualization. Since many cases are actually successfuly managed by an abdominal drain, they dramatically underestimate the incidence of the disease (and over estimate surgical necrotizing enterocolitis).

So cheer up. At least you caught it. Some people still don't get it.

J Perinatol. 2006 26(1):49-54.

Discharge outcomes of extremely low birth weight infants with spontaneous intestinal perforations.

Attridge JT, Herman AC, Gurka MJ, Griffin MP, McGahren ED, Gordon PV.

OBJECTIVE: To examine discharge outcomes of extremely low birth weight infants (ELBW) with spontaneous intestinal perforation (SIP). STUDY DESIGN: A single-center retrospective cohort study of all ELBW infants admitted to the University of Virginia neonatal intensive care unit between July 1996 and June 2004. RESULTS: We found 35 patients with SIP (incidence 8.4%). The median gestational age was 25 weeks, median birth weight was 722 g, and 71% of the infants were male. Most infants (n=28) with SIP were diagnosed secondary to pneumoperitoneum; however, one-third (7) of infants<25 weeks had occult presentations without pneumoperitoneum. When controlled for gestational age, gender, multiple gestation, indomethacin, and glucocorticoid exposure, infants with SIP have a higher risk of PVL and death than infants without perforation. SUMMARY: Periventricular leukomalacia and death are significantly associated with SIP in ELBW after adjusting for gestational age, multiple gestation, indomethacin, and glucocorticoid exposure.

6:25 PM  
Anonymous Anonymous said...

neo doc ,this is why you earn every penny you make,the responsibility,the headaches,but at times great joy also.cheer up man,as long as you give your very best,you can,with good concience,sleep well at night

7:25 PM  
Anonymous I am just the mother said...

Dont beat yourself up about it. You are human arent you?

10:08 PM  
Anonymous Anonymous said...

You are a human being. We all make mistakes. Thanks for sharing your mistakes with us. We learn from you too.

10:34 AM  
Blogger Dream Mom said...

I wouldn't be so hard on yourself. Yes, it's frustrating to miss something you thought you should catch however due to the sheer volume of patients and tasks today, I am actually quite surprised there aren't more errors.

I worry less about the occasional error and more about the physician who would never have caught it.

As for Dear Son's physicians, I don't expect them to be perfect. They take great care of him and if there is a mistake, it wouldn't be a big deal. It's the service that I receive over the long haul that's important. As for Ped Neuro Doc, I am always thankful for the great job he's done for us for fifteen years and amazed that he does everything that he does, considering the sheer volume of patients. I say that because I am certain your patients feel the same way about you.

Ex Utero-Nice comment.

2:04 PM  
Anonymous Dianne said...

As everyone's been saying, don't beat yourself up. But do consider if there's any way that you can avoid this in the future. Maybe make it a rule to always look at the abdomen and bones first and only then look at the lungs when reading a cxr? I don't know if that's the best idea, but just trying to think of some way to make looking under the diaphragm part of the routine so that you don't miss unexpected findings like this. Maybe there ought to be some sort of computer program to scan for certain abnormalities (air under the diaphragm, lytic lesions, pneumothorax, that sort of thing) and bring any questionable x-rays to the attention of the radiologist. I have no idea how hard this would be to do, but it could be very helpful if it worked...

3:46 PM  
Anonymous Anonymous said...

Neonatal Doc,
What is the role of the radiologist in this incident? Part of the role of the radiologist (for which he or she gets paid, incidentally) is to read the films, and to call the clinicians if there is a significant finding on the film such as a pneumothorax or a pneumoperitoneum. This sort of cross-checking by different team members is crucial, because no one person can perform at 100% all the time.

In our NICU we have radiology rounds everyday with the radiologist, where we go over each film. Also, did you view the CXR on a computer monitor, or on a full-fledged radiology viewing system (e.g. PACS), or was it an actual (now old-fashioned) film?

8:57 PM  
Blogger neonataldoc said...

Thanks for the support. Ex utero, I figured you'd have a comment on this. For those of you who don't know, Ex utero has made spontaneous intestinal perforations his main research interest. This case was pretty interesting. The x-ray showed free air, but no other signs of NEC, like dilated loops, pneumatosis, etc, so we figured it was SIP before the surgery.

Okay, enough of the medical talk. Diane, you're right, and I try to make it a rule to look at the abdomen first on a CXR. I just forgot the rule this time.

Imf, good point. We have old fashioned films up in the NICU but the radiologists have the nifty monitors. Although, like most neonatologists, I tend to initially read my own chest x-rays, I took this one to the radiologist because there was a bit of an unusual chest finding, and I wanted his opinion on that. Unfortunately, we focused on that and missed the abdomen.

5:30 PM  
Anonymous Anonymous said...

From Seneca the Younger. "errare humanum est perseverare diabolicum": "to err is human; to persist is of the Devil"

Primum non nocere de indere curare
(1st do not harm then cure if you can)
from Hippocrates' Epidemics, "Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things: to help, or at least to do no harm."

It's ok for you to focus on an unusual chest finding, but not the radiologist ...he should have spotted a perf. even if the clinical information was misleading the radiologist. You did the right thing and sought advice from the expert in his wouldn't be at fault in a court of law my friend.

7:21 PM  
Blogger Judy said...

And then there was the abdominal film that several of us were reviewing when another of our neonatologists strolled into the room. He had no idea we were looking for possible free air in the abdomen, so he wasn't distracted from the real problem.

Kid had a mid-sized pneumothorax.

It really sucks when you get so focused on what you think is the (only) problem that you miss something else.

Fortunately you did find it and the baby is doing well now -- and you were kind enough to share this so others can learn from it.

8:54 PM  
Anonymous Anonymous said...

Missed as in incompetent!! How can u forget something so important? What if it was your child laying there helpless depending on someone u thought was qualifed to take care of them and it turned out that apparently they have better things to do!?

Is this child still alive or did u kill baby from your ignorance or forgetfullness? I know the hospital doctor situation tooo much. You end your blog by saying that awhile from now maybe u will forget or maybe u will be tired...that's pathetic, that's not taking responsibility for what happened or not learning from your so called "mistake" which I would word it as incompatence.

I think doctors that can't do their job should not be able to even get close to any human being when it comes to care, and if u had a dog doc I believe it would end up croaking and not on it's own, just from not taking care of it. I hope the family is on to what u have done, and if I knew exactly who u were I would have my question answered as well.

5:43 PM  
Anonymous K.K. said...

Wow, anonymous, whoever you are that posted above me. You are obviously not in the medical field. Doctors are human too. What if every time you made a mistake at work someone died? It's easy to throw stones when you've never been in such a situation, isn't it. I'm apalled at your insensitivity.

As for you, Neo Doc-- at least you caught it! And, I'm impressed by your healthy attitude and ability to move on. I'm an aspiring NNP and I lose a lot of sleep at night worrying about making mistakes. If we dwell on all our mistakes, we would not be able to function.

10:59 PM  
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11:34 PM  

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