I Feel Rotten

[The White Coat Investor]

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How long does it take to quit feeling rotten when you screw up?

I saw a 16 year old the other night at 2 am on a very busy shift. Chief complaint was headache. She also was complaining of "seeing someone on her left side." History of congenital optic nerve atrophy. Slit lamp exam was normal. Intraocular pressures normal. Neuro exam normal with the exception of CN II, but then again, she had optic nerve atrophy and her normal vision was worse than 20/200 bilaterally. How reliable could my peripheral vision exam be when she can't count fingers 2 feet straight ahead of her? Head CT was normal. Her headache got better with phenergan, fluids, toradol, and imitrex.

She went home and seized, came back and was diagnosed with an occipital stroke. Now I'm the M & M monkey. Worse than that, she is the step-daughter of a friend of my wife's (I actually heard the second part of the story from her, then looked it up myself on my next shift.) I mean, what the hell, whoever heard of a 16 year old stroking? And since when do strokes come in with a headache? (it was non-hemorrhagic of course, or the CT would have picked it up.) Now I feel like a ******* and can't stop thinking about the case. Do you ever get used to that feeling?

 

[Apollyon]

I missed an RPA (retropharyngeal abscess, for the uninitiated), and the guy came back two days later (you may have read my account of this). He was worse, and ENT did an awake intubation before going in. The guy got mediastinitis, trached, ENT went back in once more, and thoracic sx went in twice.

How do I know this? Because I followed the case every day, hoping he wouldn't die.

He didn't. Was DC'd last week. And, he thinks I saved his life from my discharge instructions.

How long does it last? I don't know.

 

[Sessamoid]

How long does it take to quit feeling rotten when you screw up?

Depends, I guess. It doesn't sound like you screwed up. You did a remarkably thorough workup, and dispositioned the patient exactly the same way pretty much all of us would. I could never fault somebody for missing an ischemic occipital stroke in a teenaged patient who is functionally blind. What a bizarre combination of factors!

 

[mikecwru]

How long does it take to quit feeling rotten when you screw up?

I saw a 16 year old the other night at 2 am on a very busy shift. Chief complaint was headache. She also was complaining of "seeing someone on her left side." History of congenital optic nerve atrophy. Slit lamp exam was normal. Intraocular pressures normal. Neuro exam normal with the exception of CN II, but then again, she had optic nerve atrophy and her normal vision was worse than 20/200 bilaterally. How reliable could my peripheral vision exam be when she can't count fingers 2 feet straight ahead of her? Head CT was normal. Her headache got better with phenergan, fluids, toradol, and imitrex.

She went home and seized, came back and was diagnosed with an occipital stroke. Now I'm the M & M monkey. Worse than that, she is the step-daughter of a friend of my wife's (I actually heard the second part of the story from her, then looked it up myself on my next shift.) I mean, what the hell, whoever heard of a 16 year old stroking? And since when do strokes come in with a headache? (it was non-hemorrhagic of course, or the CT would have picked it up.) Now I feel like a ******* and can't stop thinking about the case. Do you ever get used to that feeling?

What do you think was the cause of the stroke?

It's a common pimp question that the ischemia of stroke doesn't cause mental status changes or headache in the cortex (unless bilateral) but we've all had gomers with big MCA strokes that have either of the two from the edema from the stroke process. Also, I don't know the exact reasoning, but posterior fossa stuff is much more prone to causing a headache with ischemic strokes.

You sound like you did more than most others would have done. Even if you do stuff right, people still die or get hurt.

The only thing you didn't mention was...did you check for papilledema?

mike

 

[spyderdoc]

Even if you scanned her, it would have been wnl since sx were acute....Occipital CVA is not clinically easy to pick up, esp w/ previous congential optic nerve probs....
Just a thought for the fleas working her up in house, one thing to consider in her case is a DVT along w/ a PFO... Even though she is only 16, she can have a hypercoaguable condition....
I would also feel bad, but not lose sleep over it....

 

[Jeff698]

did you check for papilledema?

This is my not-so-secret fear in medicine. I couldn't see papilledema if my life depended on it. Hell, I still feel like celebrating when I can actually see an optic disc. I'm hoping I get better at this but my learning curve has been awfully steep on this issue.

How comfortable do most of y'all feel with dedecting papilledema? If you are comfortable with it, how long did it take for you to get that way?

Also, what is the sensitivity/specificity of detecting ICP changes via papilledema?

Take care,
Jeff

 

[Homunculus]

How reliable could my peripheral vision exam be when she can't count fingers 2 feet straight ahead of her?

everyone misses diagnoses. don't beat yourself up over it-- most people would have handled it the same way. and the rarities you catch will far outnumber the ones you miss.

my only questions--did she have a history of migraines? what was her headache history (worse in AM/vasalva/sudden onset/similar HA in past etc etc)? did it localize? any coag risk factors?

most complicated kids like this i run past peds neuro-- esp with the comorbid optic nerve atrophy (for the reason you stated and i quoted). i doubt they would have objected to seeing her.

--your friendly neighborhood hates how the retrospectometer is always right caveman

 

[jonahhelix]

Because it's your own "miss," only time will ease the (underserved!) angst. But I don't think you should be upset with yourself... just the odds.

It's what scares me most about our field. I just don't think the math is in our favor, you know? Gosh, I can't count the number of HAs that I have sent out, and my career is just starting. The 1/10,000 bomb is going to hit us all at one point or another...

Anyway, sorry that it happened - to the patient, and to you - but I'm sure there's something to learn from it... even just how to handle bad outcomes.

Take care.

 

[Febrifuge]

I think there's a maxim that goes something like, "the ability to diagnose like a superhuman comes with experience -- but experience comes with years of making diagnoses like a normal human."

I think you did a lot more than some would have, and I don't know that you "screwed up." I think you failed to hit a very small bullseye on a moving target.

 

[beyond all hope]

Drunk with mild HA from falling. Didn't pass out, just slipped and fell. Really tiny contusion on the back of his head, A+O, nonfocal neuro exam, no N/V, no dizziness, no LOC. Tylenol and let him sleep it off. Seized in my ED 4 hours later. Rushed him to CT to find a frontal ICH. I don't think I really made any mistakes in this case, but I should have been more conservative and scanned the guy on admission.

Patient comes in 'Respiratory distress'. Pupils constricted, no pulse. Resuscitated successfully w/EPI, Dopamine, usual PEA protocol. FAST exam showed a small amount of FF in the belly, but he wasn't bleeding, right? We rolled him 2 hours later and found a tiny GSW hole. He wasn't even bleeding out of it. Call trauma, went to OR. Take home point: always fully examine the patient.

Patient in on the floor with tachycardia, profuse sweating, transferred to me in the SICU. I was told he has this all the time, just being transferred up because we have extra beds. I have him THREE DAYS before I order an EKG and find he has Atrial flutter. I MISSED the first EKG that I saw with A flutter with obvious sawtooth pattern. Was converted by Cards two days later. This is probably the dumbest mistake I've ever made in medicine.

I don't think I'm a bad doctor but I make mistakes. Lots of them. I try to be thorough but you can't see everything.

Medicine is damn tough. The problem is that we're expected to be perfect and make no mistakes every day and every decision we make. It's just not realistic.

 

[The White Coat Investor]

What do you think was the cause of the stroke?


The only thing you didn't mention was...did you check for papilledema?

mike

Dunno the cause....smoking and OCPs were risk factors in retrospect (I didn't ask)

Yes, there was no papilledema, but its not like I didn't scan her. There was no evidence of increased Intracranial pressure on the CT--much higher sens and spec than my non-dilated fundoscopic exam

 

[The White Coat Investor]

everyone misses diagnoses.

most complicated kids like this i run past peds neuro-- esp with the comorbid optic nerve atrophy (for the reason you stated and i quoted). i doubt they would have objected to seeing her.

--your friendly neighborhood hates how the retrospectometer is always right caveman

That's definitely what I regret not doing. But even if I had....could I have helped her at all? She just would have seized in house instead of at home. I couldn't have given her thrombolytics even if she had come in with stroke written on her forehead.

 

[Sessamoid]

That's definitely what I regret not doing. But even if I had....could I have helped her at all? She just would have seized in house instead of at home. I couldn't have given her thrombolytics even if she had come in with stroke written on her forehead.

I doubt anything you could have done would have changed the outcome significantly.

 

[m and m]

I doubt anything you could have done would have changed the outcome significantly.

Amen,

Say you were suspicious of stroke. What were you going to do,
get an MRI from the ER ,
try to convince a pediatrician that this 16 year old with a head ache is really a stroke

Say you do get the MRI and you do admit the kid to peds. I guess then they could of done that great intervention they do for strokes ... wait ... no, thats for MIs. My bad.

How long does it take to get rid of the feeling. I dont think it ever really goes away wich is why you see plenty of doctors doing weird work ups on patients that don't need them because they had one really weird case at some point earlier in their career that reminds them of that one.
I had a case as an intern on a hep C, GI bleeder with a Hct of 8 were we could not get IV access. I placed a central line on the R side but it ended up going up to the carotid so it was pulled. Basically I screwed it up. I signed off and found out the next day that no one ever managed to get a line. A senor ER reseident couldn't get it, attending couldn't get it, surgery couldn't get it (did I menton this guy was like 500 pounds). The patient coded and died 2 hrs after I left. That case sticks in my mind and since then I have become anal retentive about which way the bevel is pointing when I place a line.
That is how we learn some leasons 🙁 .

 

[m and m]

Amen,

Say you were suspicious of stroke. What were you going to do,
get an MRI from the ER ,
try to convince a pediatrician that this 16 year old with a head ache is really a stroke

Say you do get the MRI and you do admit the kid to peds. I guess then they could of done that great intervention they do for strokes ... wait ... no, thats for MIs. My bad.

How long does it take to get rid of the feeling. I dont think it ever really goes away wich is why you see plenty of doctors doing weird work ups on patients that don't need them because they had one really weird case at some point earlier in their career that reminds them of that one.
I had a case as an intern on a hep C, GI bleeder with a Hct of 8 were we could not get IV access. I placed a central line on the R side but it ended up going up to the carotid so it was pulled. Basically I screwed it up. I signed off and found out the next day that no one ever managed to get a line. A senor ER reseident couldn't get it, attending couldn't get it, surgery couldn't get it (did I menton this guy was like 500 pounds). The patient coded and died 2 hrs after I left. That case sticks in my mind and since then I have become anal retentive about which way the bevel is pointing when I place a line.
That is how we learn some leasons 🙁 .

On the other hand, apperentely I'am not anal about mi spelllling ... at all.

 

[ERMudPhud]

How long does it take to quit feeling rotten when you screw up?

It usually takes weeks before I feel like my normal self again but you never forget your mistakes or really get over them. Every time you see a similar patient in the ED again you always feel a bit sick and sad. I still remember a similar 16 year old with fever headache and neck stiffness. LP was negative and she had a chronic headache history which her neurologist had dx'd as migraines. A week later she was diagnosed with psuedotumor but by that time her vision was pretty crappy. I spent a long time praying her vision would get better and vowed that every LP from now on no matter what I thought I was ruling out would get an opening pressure measured. Since then I've found another psuedotumor and a dural sinus thrombosis that I might otherwise have missed.

 

[ERMudPhud]

Yes, there was no papilledema, but its not like I didn't scan her. There was no evidence of increased Intracranial pressure on the CT--much higher sens and spec than my non-dilated fundoscopic exam

To answer Jeff's question I think we all probably suck at finding papilledema consistently in a nondilated headache patient (especially when they have photophobia)

Don't assume the CT will tell you much about ICP. Two good examples: NPH=hydrocephalus but no elevation in ICP. Pseudotumor=normal CT but papilledema and sky high ICP. Other than increased ICP from mass effects I suspect CT is probably pretty crappy.

 

[Purulent DC]

How comfortable do most of y'all feel with dedecting papilledema? If you are comfortable with it, how long did it take for you to get that way?

I did a 2 week Ophtho elective as a 4th year med stud. and still didn't learn how to see the fundus that well. Unless the patient is in a dark room and dilated, I don't feel reliable with my exam AT ALL. I'd like to use a panoptic ophalmoscope more because it increases the field of view, but my experience with them is limited. I just did a neuro rotation and spent a few clinic shifts with a nurse practitioner who was very thorough, except that she'd do the fundus exam with the room lights ON. The first time I saw her do this I walked over to the light switch and ask if she like the lights off. When she said, "No", I knew that she was gaining very little (if not faking) the exam.

In short, I think my fundus exam is pretty useless.

 

[peksi]

In short, I think my fundus exam is pretty useless.[/QUOTE]

This is why I teach our residents how to measure the optic nearve sheath diameter by ocular US. ONSD is essentially an evaluation for papilladema. there is some skill and a learning curve but this works well in our department. I still do a slitlamp exam but add this on as well. ONSD > 5 mm is abnormal in adults. Plus I've confirmed and excluded more RD by US than by fundic exam...it's just easier to interperet.

Paul

 

[Annette]

About a year and a half ago, I, along with the senior, ED resident, and ED attending missed xanthochromia in a patient with a ha. The patient came in the following week after a massive bleed. I still cringe when I get a ha patient.

I had a 22 year old stroke after taking ephedra. He came in with word salad. The mother wasn't around when he stroked. Talk about taking a difficult history.

 

[Purulent DC]

This is why I teach our residents how to measure the optic nearve sheath diameter by ocular US. ONSD is essentially an evaluation for papilladema. there is some skill and a learning curve but this works well in our department. I still do a slitlamp exam but add this on as well. ONSD > 5 mm is abnormal in adults. Plus I've confirmed and excluded more RD by US than by fundic exam...it's just easier to interperet.

Paul

Thanks for the input Dr. Sierzenski,

I have heard of this technique, but it's not discussed in the Ma & Mateer EM US book. Granted it is pretty fast to slap some gel and a linear probe on the eyelid, but has this technique (and the magic cut off number of 5mm) been validated with adequate studies? Is this technique used by other depts. than EM (e.g neurology, neuro. surg., etc.). I should probably do a lit. search on this, but is the sensitivity great enough to rule out papilledema if the ONS is 4.9mm, etc.

 

[peksi]

Thanks for the input Dr. Sierzenski,

I should probably do a lit. search on this, but is the sensitivity great enough to rule out papilledema if the ONS is 4.9mm, etc.

This technique and information is in the optho liturature. We are currently testing it's accuracy to measure ICP. Often 4.5mm is actually used as a top cut off is some studies. I'm not advocating anyone abondon their current tools, as a matter of fact I feel that there are often not enough slit lamp and IOP measurements taken on patients with HA, or visual complaints. Our evidence right not is anecdotal, but I can tell you from my personal operator standpoint, it is easier to measure an ONSD via ocular US than to view the optic disk via slit lamp etc. Maybe it's just me.

The body of liturature is increasing

Ultrasonography
Standardized A-scan orbital ultrasonography precisely measures the diameter of the optic nerve sheath.
If this diameter increases in primary gaze and diminishes by 25% in eccentric gaze (30° test), then increased subarachnoid fluid surrounding the optic nerve is presumably present. This finding is consistent with papilledema if it is bilateral.

The orignial studies with this cam out of europe and included such techniques as intrathecal sterile saline injection to increase ICP...not something one could get through the IRB today!

[Optic nerve sheath enlargement and reversal of optic nerve head in pseudotumor cerebri]

[Article in Hebrew]

Kesler A, Yaffe D, Shapira M, Kott E.

Dept. of Neurology, Meir Hospital, Kfar Saba.

Using standard cerebral computerized tomography (CT), we diagnosed pseudotumor cerebri (PTC) and correlated the CT findings with CSF pressure and severity of visual impairment. 13 patients with a clinical diagnosis of PTC were compared with 20 age-matched controls with headache, but without papilledema or other neurologic signs. Cerebral CT consisted of axial sections of the posterior fossa, including the orbits. In all subjects the diameter of the optic nerve sheath, reversal of the optic nerve head, presence of empty sella, and size of the ventricles, cisterns and sulci were evaluated. There were no differences in basal cisterns and ventricles between those with PTC and control subjects. Empty sella was found in 6 of 13 PTC patients, compared with 1 of the 20 controls. Optic nerve sheath diameter in controls ranged from 3.5-5.0 mm (average 4.2 +/- 0.54 mm) but from 4.5-9.0 mm (average 6.8 +/- 1.54 mm) in those with PTC. Reversal of the optic nerve head was seen in 4 cases of PTC but in none of the controls. In PTC patients with opening CSF pressure greater than 270 mm water, the diameter of the optic nerve was wider than 7.5 mm. Thus, in most cases of PTC, bilateral enlarged optic nerves can be measured by standard cerebral CT and intracranial space-occupying lesions can be excluded as well. Moreover, reversal of optic nerve head, and empty sella can frequently be seen on CT in those with PTC.

This study uses CT to measure the ONSD but US is an accepted modality.

Paul

 

[PlayHard]

To answer Jeff's question I think we all probably suck at finding papilledema consistently in a nondilated headache patient (especially when they have photophobia)

Don't assume the CT will tell you much about ICP. Two good examples: NPH=hydrocephalus but no elevation in ICP. Pseudotumor=normal CT but papilledema and sky high ICP. Other than increased ICP from mass effects I suspect CT is probably pretty crappy.

Based on the paper posted by Dr. Sierzenski, wouldn't we expect CT to pick up most cases of significantly increased ICP by way of dilated optic nerves? Why would pseudotumor cerebri be an exception?

 

[peksi]

Based on the paper posted by Dr. Sierzenski, wouldn't we expect CT to pick up most cases of significantly increased ICP by way of dilated optic nerves? Why would pseudotumor cerebri be an exception?

My only issue here is that this is not a common abnormality that general radiologists, or radiology residents look for, however neuroradiologists do. I would agree that with 3rd and soon evern fourth generation CT, this finding could and should be identified.

Paul

 

[ERMudPhud]

My only issue here is that this is not a common abnormality that general radiologists, or radiology residents look for, however neuroradiologists do. I would agree that with 3rd and soon evern fourth generation CT, this finding could and should be identified.

Paul

So the two pseudotumors I've seen both had CT's done on a 3rd generation scanner read (eventually) by the neuroradiologist on staff as normal. No specific comment was made about optic nerve diameter so perhaps they weren't looking for it. I wouldn't trust your CT's to tell you much about ICP unless the neuroradiologist tells you otherwise

 

[The White Coat Investor]

In short, I think my fundus exam is pretty useless.

This is why I teach our residents how to measure the optic nearve sheath diameter by ocular US. ONSD is essentially an evaluation for papilladema. there is some skill and a learning curve but this works well in our department. I still do a slitlamp exam but add this on as well. ONSD > 5 mm is abnormal in adults. Plus I've confirmed and excluded more RD by US than by fundic exam...it's just easier to interperet.

Paul[/QUOTE]


That's a good thought, and doesn't take much longer than a fundoscopic exam anyway. Maybe I'll start doing that.