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....