sent home from the ER with a life-threatening condition. now what?

June 21, 2014 6:29 PM

I had a health scare and a physician in an emergency room misdiagnosed me. What should I do? (a question especially for the md's here)

When I went to bed Wednesday evening everything was normal. I awoke Thursday morning to excruciating pain in my right shoulder and right ribcage. Some of you may remember from a previous question here that I had just spent two months in bed, recovering from a lumbar fracture. I thought I was probably just sore and decided to rest that day. When on Thursday evening the pain hadn't lessened, I went to an emergency room. (This is an american/international hospital in Shanghai.)

The surgeon on staff was one of the head physicians of the hospital. He listened to my story, did x-rays and, when it became clear that none of my bones were the reason for my discomfort, prescribed me Percocet and sent me home, saying there wasn't much more that an emergency room could do for me and that it had to be something else. He did call me at about 1am to let me know that my EKG was abnormal and that I should follow up with a Neurologist (not a Cardiologist? I am sure he said Neurologist) but he did not think I had to come back that night. I have a low heart beat, which is hereditary on my maternal side, and it's fairly normal for me to freak out physicians and EKG monitors. If there is a bell, it will go off.

The pain did not get better on Friday and on Saturday I awoke to it being so bad I couldn't breathe properly. Within ten minutes of waking up I knew something was very wrong and hauled ass back to the same emergency room. This time, another doctor was on call and upon me telling him of my symptoms and that I had spent two months in bed he immediately ordered a CT scan. Less than an hour later phrases like "life threatening" and "real emergency" were thrown around and I was on blood thinners. I had massive blood clots in both lungs.

What is the right thing for me to do here? All the other physicians I have met in this hospital since I was admitted seem incredulous over my having been sent home by the first physician. One senior physician was so mad, he had visible problems remaining calm in front of me. I am not sure if I should be angry or disappointed or scared given that I was sent home with a life-threatening condition undiagnosed and that is why I am asking for your opinion. Should I complain to hospital management? Ask for my bill from that ER visit to be forgiven? Do something entirely different or nothing at all?

posted by krautland to Health & Fitness (19 answers total)

I would document & write a letter of complaint but not before checking with a lawyer first.
posted by St. Peepsburg at 6:47 PM on June 21, 2014 [1 favorite]

Your complaint is clinical, so you have to pursue it in on those grounds. That's not a fight you can initiate through the billing office. Do you know how many people suddenly have clinical complaints the moment they get their bills? Real clinical complaints deserve attention from clinical management. And then maybe they can get you a deal on the bill, too. On preview, I agree you might want to check in with a lawyer first.
posted by ThePinkSuperhero at 6:49 PM on June 21, 2014

You seem to have a number of the physicians already on your side. I'd get their opinion (among others) on how to proceed.
posted by colin_l at 6:57 PM on June 21, 2014 [3 favorites]

I'm still dumbfounded that your postsurgical care consisted of, from your earlier post, lying alone flat on your back for two months. IANAD, but I do have a reconstructed spine, and though your case may be a snowflake, my understanding is that the modern standard of care is to get the patient up and moving ASAP. My speculation is that the bad care that led to your emboli started then. And was, of course, acutely complicated by the surgeon who missed them this week.

Of course, China doesn't have the tort system we do, so.

But the first thing is: get better. Are the clots dissolved? Are you ok? Are you mobile? Have you had PT?
posted by Dashy at 7:11 PM on June 21, 2014 [5 favorites]

Response by poster: you guys say lawyer but I am in china. even though this hospital is american-run, the contract I signed here clearly states I am subject only to chinese and hongkongnese laws and courts.

Dashy, your reaction is warranted. chinese doctors seem to lose interest in their patients once surgery is over. this has become more clear to me after talking to the US doctors here. the clots are dissolving but I will be on thinners for six months. I am mobile but inpatient until monday or tuesday. PT will come.
posted by krautland at 8:11 PM on June 21, 2014

I'm so sorry this happened to you, krautland, and hope you are on the mend! I don't have any advice re: how to handle the misdiagnosis, but just wanted to mention that since you'll be on blood thinners, be careful about any herbal supplements, NSAIDs, etc. that you might also take -- they can thin the blood, too. It sounds like your new doctors are on top of everything and have probably already mentioned this, but given what's happened I just wanted to put in my two cents on that score.
posted by scody at 10:12 PM on June 21, 2014 [2 favorites]

Thank God you are alive.

I would still speak to a lawyer. Just because you signed something does not necessarily mean anything.

Lawyer.
posted by St. Alia of the Bunnies at 10:23 PM on June 21, 2014 [1 favorite]

IANAD! Aspirin is a blood thinner. Some medical person should check the status of your blood periodically to be sure it is not too thin, or too thick and clotting again. Be careful about bumping into things - you will probably bruise easily. Do not cut yourself; if you do, try to apply direct pressure to stop the bleeding. Good luck. Is there anyone in China with you who can act as an advocate for your care , and maybe check on you occasionally?
posted by Cranberry at 11:53 PM on June 21, 2014

I am so, so relieved that a different doctor found the cause and was able to treat it.

You're going to be on blood thinners for six months? You need to get a lawyer who specializes in medical malpractice, because you will need someone who can provide strong evidence that, had the first surgeon bothered to order a CT Scan (which anyone with even a modicum of knowledge would have done when you explained that you'd been flat on your back for months), you would not have needed this treatment (or not for as long), and all of the disadvantages/side effects/expenses that are attendant to it. Even if the other surgeons were horrified and enraged, they are probably not going to be on your side when it comes to suing the hospital for reimbursement.
posted by tzikeh at 12:10 AM on June 22, 2014

Best answer: I'm sorry this happened to you! I can't speak to the malpractice and IANAD, but I can speak a bit to blood clots-- I just had one myself, and they run in my family.

Being on bed rest is one of the most classic ways of getting them, so I'm not sure if they'll run any additional test (such as checking for genetic markers), but it is something to ask them about. Your 6 month bout on thinners is completely normal-- even had they diagnosed you the first time, you would still be on them for this length. The typical drugs (Heparin and Warfarin) do require that you test your blood often to make sure your clotting level is correct-- neither too high or too low. Some new drugs (Xaralto, and I think there are others) do not require this... you take it and that's that, but it's really important you take it at the same time every day. Some doctors won't take x-rays to make sure the clots are gone, and that's something for you to decide if you want to push for. If you ever have symptoms after you're off the thinners, you can always request an x-ray or an ultrasound and they're usually pretty quick about getting you in.

Unfortunately, you'll need to stay away from most over the counter drugs--anything that contains aspirin or IBprofin, but Tylenol is ok. Clotting is also directly tied to the amount of vitamin K you have (especially prevalent in leafy greens), so don't start suddenly eating more or less of these or start or stop a multivitamin without talking to your doctor. If your teeth bleed when you're brushing your teeth, go to the doctor-- your level isn't right. Also, lay off the alcohol, because you have no tolerance now. (I got tipsy off of half a beer.)

You might also want to ask about whether you should be wearing compression socks. If so, ask about what pressure (in mmHG), measure yourself, and you can order them online for much cheaper-- and not the generic pasty white hospital ones. (I always get compliments on my rainbow striped ones when I go to the doctor, but there's the much more classic black for work.) My last bit of advice-- don't pick your hangnails!

I hope you feel better! Feel free to message me if you have any questions...
posted by veryhappyheidi at 5:52 AM on June 22, 2014 [2 favorites]

Response by poster: Heparin and Warfarin are exactly what I have been put on and apparently will stay on. I wil ask about compression socks tomorrow, didn't know about that.
posted by krautland at 7:29 AM on June 22, 2014

Best answer: You need follow up and ongoing medical care from a doctor you trust. Warfarin does require careful titration and ongoing evaluation. This is important.

-----

So while it sounds like the first doctor was wildly incompetent, consider that medicine that is not like an arithmetic problem.

Doctors are wrong all the time because there is precious little in medicine that is completely obvious, presents in a totally typical and predictable way, or looks exactly the same from person to person. Further, doctors are humans who operate at a range of ability depending on what else happened to them that day, how little sleep they've gotten, what cases they've seen recently, etc. While some doctors might show a consistent pattern of wrong diagnosis and that should be addressed, most have a range of skill and ability with strengths in some areas and weaknesses in others.

Finally, the ER is not the right place to get definitive diagnoses, and it is almost always important to get follow up care from a primary care provider after an ER visit.

Yes, the ER doctor was in fact wrong. I guess you may as well ask for bill forgiveness - what do you have to lose? If it were me though, I'd put my energy into getting well now and getting the best care you can moving forward.

-----

Stuff to be looking at is your clotting time - ask specifically about the PT, PTT, and INR blood tests as these should be carefully managed with the warfarin.

Google pulmonary embolism - perhaps what you had.

Physical therapy - no idea what the standards are around this in China but you would almost definitely benefit.

Are you mobile yet? Movement, if safe, is probably very important for you.
posted by latkes at 11:53 AM on June 22, 2014 [2 favorites]

Krautland, I should have said this sooner, but please do feel free to memail me if you need the ear of a fellow spinal patient. I sure did. I'll be thinking of you, and hope you continue to improve.
posted by Dashy at 12:23 PM on June 22, 2014

As a data point I have been an EMT for about three months which means I have 1/100th the knowledge and 1/10000th the experience of an ER Doctor and as soon as I read the description of your symptoms and your recent medical history my first thought was embolism.

Doctors are human, ERs are busy and confusing places, patient symptoms are always clearer in hindsight but to my eyes to not look for an embolism was a monumental mistake.

Please contact a lawyer, this may not be the only mistake the doctor has or will make, and even if it is it's important that the hospital administration knows about it. At that point they may offer to wave bills, etc.

I hope things go smoothly from this point and you heal well. Feel better.
posted by rip at 3:34 PM on June 22, 2014

What strikes me is how the doctor who made the catastrophic mistake is "one of the head physicians at the hospital" and the less senior doctors seemed livid (possibly knowing him to be incompetent but too powerful?). Sounds like you could potentially do a good thing if you go to a lawyer and find out if you can sue for malpractice, helping to add a black mark to that senior doctor's record.
posted by yoHighness at 5:51 PM on June 22, 2014

Heparin doesn't usually require the same frequent blood testing as warfarin, but is way more expensive. Heparin shots have fewer drug interactions though so they're usually the first thing they use to stabilize blood clotting, then switch the warfarin or some other mix. If you're a heavy or moderate drinker you MUST be honest with your doctor because alcohol + warfarin is really horribly bad and there are alternatives. You also need to get a list of what medication and foods you need to avoid. Most antibiotics are out for example.

I would also suggest getting a Chinese-medical alert bracelet that says warfarin on it because if you get in a car accident and can't tell the ER about warfarin, you could bleed out fast before they figure out what medical records you have.

Six months is pretty normal for blood thinners after clots from a likely event (not an underlying condition). You may want to ask for physio to help you recover from the bed-rest damage to your overall system.

I can't imagine getting a lawyer to follow a medical malpractice suit in China for an expat. The idea just seems ludicrous to be honest. Be glad you're alive, ask for a serious discount or for your bill to be waived and avoid that doctor. The medical and legal system in China is freaking brutal on locals, let alone on a foreigner who presumably has few connections to navigate it.

If the hospital was owned by a US-based company, get a US-based lawyer over there maybe. Otherwise, post your experience anonymously to the expat boards to not recommend that hospital and doctor and move on.
posted by viggorlijah at 8:18 PM on June 22, 2014 [1 favorite]

Response by poster: *Google pulmonary embolism - perhaps what you had.*
I found this on medscape and it's a direct hit. I have an english-language emergency room report but my gf took it home. I can upload it if desired. http://emedicine.medscape.com/article/300901-overview

*PT, PTT, and INR blood tests*
noted, this is really helpful, thank you :-)

I am mobile and found a german physio specialist at the hospital. just secured my first therapy session for friday. yay!

*a Chinese-medical alert bracelet that says warfarin on it*
good call, will do.

*one of the head physicians at the hospital*
the doc who misdiagnosed me is a US MD, Assistant Chief Medical Officer, Chair of Emergency Medicine & Emergency Medicine Physician. so yeah, senior.

just as I was writing this, the doctor in question walked in and apologized for having missed my issue. he thinks he could not have known, which I disagree with, but I respect that he came here to talk. I have asked the hospital to forgive thursdays bill and if they agree, I will be ok with leaving it at that. patient services told me that complaints such as mine will be investigated by an outside doctor before a decision is made, leading me to hope that they will at the very least take a close professional look at what went wrong that night.
posted by krautland at 9:14 PM on June 22, 2014

Response by poster: for the record: I was able to copy the complete medical file the hospital had on me today. please let me know if there is anything I should look for in it.
posted by krautland at 4:17 AM on June 23, 2014

Without knowing all of the symptoms you manifested and test results from your first visit, it's hard to say whether there was an obvious miss of PE by the first doc you saw. In practice, generally, PE is not always straightforward, as it can cause a wide variety of possible symptoms in different age ranges and gender. It is sometimes quite difficult to pin down, and takes an acuity and experience in the physician that gathers in all the relevant history and data. As catching a PE can be quite tricky, it isn't an immediate failure of the physician, depending on what confounding factors were present or absent in your first visit.
Regardless, I'm very glad it was nailed down quickly on your second visit.
posted by Cold Lurkey at 9:41 PM on June 23, 2014